Provider First Line Business Practice Location Address:
227 BLUEGILL LN
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:
83202-1898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-7940
Provider Business Practice Location Address Fax Number:
208-237-7924
Provider Enumeration Date:
08/05/2006