Provider First Line Business Practice Location Address:
700 E ALICE 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:
83221-4925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-1200
Provider Business Practice Location Address Fax Number:
208-785-8516
Provider Enumeration Date:
01/19/2007