Provider First Line Business Practice Location Address:
335 E LEWIS ST STE 10
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:
83201-6408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-775-7123
Provider Business Practice Location Address Fax Number:
208-550-3256
Provider Enumeration Date:
01/03/2019