Provider First Line Business Practice Location Address:
494 N MERIDIAN 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:
83221-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-200-8888
Provider Business Practice Location Address Fax Number:
208-785-6170
Provider Enumeration Date:
02/16/2011