Provider First Line Business Practice Location Address:
777 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
BUILDING A, SUITE 201
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-5175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-239-2737
Provider Business Practice Location Address Fax Number:
208-239-3778
Provider Enumeration Date:
12/14/2011