Provider First Line Business Practice Location Address:
373 W HIGHWAY 39 STE 1
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:
83221-5228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-557-9450
Provider Business Practice Location Address Fax Number:
208-561-7111
Provider Enumeration Date:
04/06/2022