Provider First Line Business Practice Location Address:
407 E 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-913-2273
Provider Business Practice Location Address Fax Number:
208-567-5615
Provider Enumeration Date:
05/16/2024