Provider First Line Business Practice Location Address:
5230 W MOONLIGHT MINE RD
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:
83201-9013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-548-7312
Provider Business Practice Location Address Fax Number:
954-548-7312
Provider Enumeration Date:
08/28/2026