Provider First Line Business Practice Location Address:
701 E ALICE 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:
83221-4925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-782-2625
Provider Business Practice Location Address Fax Number:
208-785-1003
Provider Enumeration Date:
03/01/2016