Provider First Line Business Practice Location Address:
6000 S 5TH AVE
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:
83204-5075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-8400
Provider Business Practice Location Address Fax Number:
208-232-6018
Provider Enumeration Date:
12/08/2018