Provider First Line Business Practice Location Address:
1151 HOSPITAL WAY BLDG A
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:
83201-2763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-6616
Provider Business Practice Location Address Fax Number:
208-232-6618
Provider Enumeration Date:
07/24/2006