Provider First Line Business Practice Location Address:
700 EAST ALICE STREET
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:
83221-0400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-8517
Provider Business Practice Location Address Fax Number:
208-785-8516
Provider Enumeration Date:
12/29/2006