Provider First Line Business Practice Location Address:
651 MEMORIAL DR
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:
83201-4071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-239-1000
Provider Business Practice Location Address Fax Number:
208-239-2136
Provider Enumeration Date:
08/11/2006