Provider First Line Business Practice Location Address:
4155 YELLOWSTONE AVE
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:
83202-2385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-0020
Provider Business Practice Location Address Fax Number:
801-396-7066
Provider Enumeration Date:
05/13/2021