Provider First Line Business Practice Location Address:
1400 E TERRY ST, BLDG 63, 7TH FLOOR
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-3156
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2026