Provider First Line Business Practice Location Address:
98 POPLAR ST
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:
83221-1758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-721-1030
Provider Business Practice Location Address Fax Number:
877-993-1515
Provider Enumeration Date:
04/25/2007