Provider First Line Business Practice Location Address:
444 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
SUITE 411
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:
208-478-6677
Provider Business Practice Location Address Fax Number:
208-478-1363
Provider Enumeration Date:
09/13/2006