Provider First Line Business Practice Location Address:
1441 PARKWAY DR 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:
83221-1667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-3446
Provider Business Practice Location Address Fax Number:
208-980-7241
Provider Enumeration Date:
11/09/2023