Provider First Line Business Practice Location Address:
427 N 4TH AVE
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:
83201-6341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-2052
Provider Business Practice Location Address Fax Number:
208-478-1601
Provider Enumeration Date:
02/18/2008