Provider First Line Business Practice Location Address:
720 EAST ALICE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-705-6347
Provider Business Practice Location Address Fax Number:
208-785-5877
Provider Enumeration Date:
04/11/2016