Provider First Line Business Practice Location Address:
4806 HAWTHORNE 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:
83202-2325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-0016
Provider Business Practice Location Address Fax Number:
208-234-2755
Provider Enumeration Date:
08/05/2010