Provider First Line Business Practice Location Address:
210 W BURNSIDE AVE
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-4916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-5956
Provider Business Practice Location Address Fax Number:
208-238-5957
Provider Enumeration Date:
01/30/2012