Provider First Line Business Practice Location Address:
4460 KINGS WAY STE 3
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:
83202-1900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-3612
Provider Business Practice Location Address Fax Number:
208-237-5192
Provider Enumeration Date:
08/06/2007