Provider First Line Business Practice Location Address:
465 MEMORIAL DR
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:
83209-8088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-282-6000
Provider Business Practice Location Address Fax Number:
208-282-4950
Provider Enumeration Date:
04/12/2007