Provider First Line Business Practice Location Address:
190 BULLOCK ST.
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:
83202-1928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-992-5109
Provider Business Practice Location Address Fax Number:
208-237-9029
Provider Enumeration Date:
09/23/2016