Provider First Line Business Practice Location Address:
190 W BURNSIDE AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-317-8727
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2013