Provider First Line Business Practice Location Address:
246 E CHUBBUCK RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-1965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-637-2225
Provider Business Practice Location Address Fax Number:
208-637-2226
Provider Enumeration Date:
09/07/2011