Provider First Line Business Practice Location Address:
53 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:
83221-1737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-2220
Provider Business Practice Location Address Fax Number:
208-785-2228
Provider Enumeration Date:
06/23/2005