Provider First Line Business Practice Location Address:
1151D HOSPITAL WAY
Provider Second Line Business Practice Location Address:
SUITE 204
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:
208-237-2446
Provider Business Practice Location Address Fax Number:
208-237-2466
Provider Enumeration Date:
03/26/2007