Provider First Line Business Practice Location Address:
326 POPLAR 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:
83221-1741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-782-2444
Provider Business Practice Location Address Fax Number:
208-785-3115
Provider Enumeration Date:
08/25/2015