Provider First Line Business Practice Location Address:
755 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
SUITE B1
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-4869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-9393
Provider Business Practice Location Address Fax Number:
208-237-6017
Provider Enumeration Date:
09/27/2005