Provider First Line Business Practice Location Address:
444 HOSPITAL WAY STE 477
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:
83201-2744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-7832
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/04/2020