Provider First Line Business Practice Location Address:
427 N ARTHUR AVE STE B
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:
83204-3006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-2998
Provider Business Practice Location Address Fax Number:
208-232-0881
Provider Enumeration Date:
01/26/2007