Provider First Line Business Practice Location Address:
240 W BURNSIDE AVE STE D
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:
83202-4703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-904-1112
Provider Business Practice Location Address Fax Number:
866-818-2688
Provider Enumeration Date:
01/27/2020