Provider First Line Business Practice Location Address:
5202 LUCKY AVE APT A2
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:
83202-2395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-380-2249
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2023