Provider First Line Business Practice Location Address:
911 NORTH MAIN STREET
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:
83204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-8510
Provider Business Practice Location Address Fax Number:
208-235-1328
Provider Enumeration Date:
08/13/2012