Provider First Line Business Practice Location Address:
265 E CHUBBUCK RD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-2085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-417-0011
Provider Business Practice Location Address Fax Number:
888-437-2431
Provider Enumeration Date:
12/19/2016