Provider First Line Business Practice Location Address:
701 EAST CENTER ST.
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:
83205-4869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-3341
Provider Business Practice Location Address Fax Number:
208-233-3343
Provider Enumeration Date:
09/22/2005