Provider First Line Business Practice Location Address:
4257 YELLOWSTONE AVE
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:
83202-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-3940
Provider Business Practice Location Address Fax Number:
208-237-9257
Provider Enumeration Date:
09/22/2014