Provider First Line Business Practice Location Address:
246 W PACIFIC ST STE C
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:
83221-1723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-557-1113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2026