Provider First Line Business Practice Location Address:
34 SE MAIN ST
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
BLACKFOOT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83221-5094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-7274
Provider Business Practice Location Address Fax Number:
208-785-7337
Provider Enumeration Date:
10/04/2006