Provider First Line Business Practice Location Address:
707 NORTH 7TH
Provider Second Line Business Practice Location Address:
STE #F
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-424-3044
Provider Business Practice Location Address Fax Number:
208-904-0494
Provider Enumeration Date:
10/26/2010