Provider First Line Business Practice Location Address:
436 E. BONNEVILLE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-3466
Provider Business Practice Location Address Fax Number:
208-234-9686
Provider Enumeration Date:
11/03/2006