Provider First Line Business Practice Location Address:
147 W CHUBBUCK RD
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:
83202-2314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-7546
Provider Business Practice Location Address Fax Number:
208-237-9643
Provider Enumeration Date:
03/15/2006