Provider First Line Business Practice Location Address:
4815 GALENA 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:
83202-3008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-406-3683
Provider Business Practice Location Address Fax Number:
208-232-2850
Provider Enumeration Date:
06/29/2007