Provider First Line Business Practice Location Address:
850 E CENTER ST, STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-6211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-243-9308
Provider Business Practice Location Address Fax Number:
208-844-9574
Provider Enumeration Date:
07/26/2011