Provider First Line Business Practice Location Address:
98 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:
83221-1758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-239-8033
Provider Business Practice Location Address Fax Number:
208-785-9450
Provider Enumeration Date:
03/14/2013