Provider First Line Business Practice Location Address:
774 LEONIDAS ST
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:
83202-1664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-220-1944
Provider Business Practice Location Address Fax Number:
208-516-1569
Provider Enumeration Date:
06/23/2009