Provider First Line Business Practice Location Address:
4639 YELLOWSTONE AVE
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:
83202-2371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-9100
Provider Business Practice Location Address Fax Number:
208-478-9036
Provider Enumeration Date:
12/13/2006