Provider First Line Business Practice Location Address:
1400 E TERRY DR BLDG 63
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:
83209-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-240-1690
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2020