Provider First Line Business Practice Location Address:
2407 TEEPLES DR
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:
83221-5877
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-782-0242
Provider Business Practice Location Address Fax Number:
208-782-1160
Provider Enumeration Date:
06/09/2008