Provider First Line Business Practice Location Address:
476-1/2 E.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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-7243
Provider Business Practice Location Address Fax Number:
208-237-0712
Provider Enumeration Date:
08/02/2005