Provider First Line Business Practice Location Address:
1213 PARKWAY DR
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:
83221-1654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-782-3426
Provider Business Practice Location Address Fax Number:
208-782-3436
Provider Enumeration Date:
09/03/2008