Provider First Line Business Practice Location Address:
260 N BROADWAY 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:
83221-2224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-6166
Provider Business Practice Location Address Fax Number:
208-785-1748
Provider Enumeration Date:
09/20/2006