Provider First Line Business Practice Location Address:
140 S BROADWAY 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:
83221-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-569-4316
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2006