Provider First Line Business Practice Location Address:
134 W 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:
83202-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-417-0102
Provider Business Practice Location Address Fax Number:
208-242-3219
Provider Enumeration Date:
03/04/2019