Provider First Line Business Practice Location Address:
527 MEMORIAL DR
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:
83201-4063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
120-847-8333
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2026