Provider First Line Business Practice Location Address:
4650 HAWTHORNE RD
Provider Second Line Business Practice Location Address:
STE 3B
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-2376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-237-9833
Provider Business Practice Location Address Fax Number:
208-237-1800
Provider Enumeration Date:
02/20/2012