Provider First Line Business Practice Location Address:
950 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-2789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-7007
Provider Business Practice Location Address Fax Number:
208-233-2512
Provider Enumeration Date:
05/07/2007