Provider First Line Business Practice Location Address:
1151 HOSPITAL WAY # D-100
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:
83201-5091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-239-8010
Provider Business Practice Location Address Fax Number:
208-782-2974
Provider Enumeration Date:
04/23/2008