Provider First Line Business Practice Location Address:
1151 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
BLDG F
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:
208-232-1443
Provider Business Practice Location Address Fax Number:
208-239-3434
Provider Enumeration Date:
01/16/2007