Provider First Line Business Practice Location Address:
485 WEST CHUBBUCK ROAD SUITE A
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-1006
Provider Business Practice Location Address Fax Number:
208-234-8990
Provider Enumeration Date:
11/13/2006