Provider First Line Business Practice Location Address:
4080 HAWTHORNE ROAD
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-3000
Provider Business Practice Location Address Fax Number:
208-237-6024
Provider Enumeration Date:
02/13/2007