Provider First Line Business Practice Location Address:
5605 NORTHSIDE CROSSING 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:
83202-2431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-547-5062
Provider Business Practice Location Address Fax Number:
208-547-5063
Provider Enumeration Date:
03/02/2022