Provider First Line Business Practice Location Address:
444 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
SUITE 701
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-7931
Provider Business Practice Location Address Fax Number:
208-233-0423
Provider Enumeration Date:
02/28/2006