Provider First Line Business Practice Location Address:
190 BULLOCK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-1928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-534-7881
Provider Business Practice Location Address Fax Number:
208-203-7067
Provider Enumeration Date:
11/19/2025