Provider First Line Business Practice Location Address:
1250 W BRIDGE 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:
83221-5095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-785-8018
Provider Business Practice Location Address Fax Number:
208-785-3332
Provider Enumeration Date:
07/05/2024