Provider First Line Business Practice Location Address:
445 E CHUBBUCK RD
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:
83202-1815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-244-7794
Provider Business Practice Location Address Fax Number:
208-922-7242
Provider Enumeration Date:
05/15/2024