Provider First Line Business Practice Location Address:
4460 CENTRAL WAY
Provider Second Line Business Practice Location Address:
STE 2
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:
Provider Enumeration Date:
11/30/2011