Provider First Line Business Practice Location Address:
1023 YELLOWSTONE AVE
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-4478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-9551
Provider Business Practice Location Address Fax Number:
208-478-1507
Provider Enumeration Date:
01/11/2007