Provider First Line Business Practice Location Address:
625 E ALAMEDA
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:
208-237-0005
Provider Business Practice Location Address Fax Number:
208-237-7982
Provider Enumeration Date:
09/02/2006