Provider First Line Business Practice Location Address:
94 N PINE 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:
83221-2052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-352-6640
Provider Business Practice Location Address Fax Number:
208-417-0975
Provider Enumeration Date:
03/01/2019