Provider First Line Business Practice Location Address:
265 E CHUBBUCK ROAD
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:
208-237-1711
Provider Business Practice Location Address Fax Number:
208-237-9806
Provider Enumeration Date:
04/02/2013