Provider First Line Business Practice Location Address:
745 W BRIDGE ST STE F
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:
83221-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-782-9793
Provider Business Practice Location Address Fax Number:
208-782-1999
Provider Enumeration Date:
09/17/2007