Provider First Line Business Practice Location Address:
625 W PACIFIC ST STE 4
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:
83221-2034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-3310
Provider Business Practice Location Address Fax Number:
208-785-3393
Provider Enumeration Date:
12/13/2006