Provider First Line Business Practice Location Address:
4737 S AFTON PL
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-2317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-417-0623
Provider Business Practice Location Address Fax Number:
208-417-0641
Provider Enumeration Date:
09/27/2013