Provider First Line Business Practice Location Address:
34 LOUELLA 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:
83221-1609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-317-6318
Provider Business Practice Location Address Fax Number:
208-782-1074
Provider Enumeration Date:
09/03/2006