Provider First Line Business Practice Location Address:
4852 EASY 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:
83202-2514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-221-0447
Provider Business Practice Location Address Fax Number:
520-221-0447
Provider Enumeration Date:
09/30/2025