Provider First Line Business Practice Location Address:
1495 PARKWAY DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACKFOOT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83221-1639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-3063
Provider Business Practice Location Address Fax Number:
208-782-1392
Provider Enumeration Date:
09/19/2005