Provider First Line Business Practice Location Address:
270 E BRIDGE 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:
83221-2865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-8800
Provider Business Practice Location Address Fax Number:
208-785-8809
Provider Enumeration Date:
01/29/2007