Provider First Line Business Practice Location Address:
4990 VALENTY RD
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-1883
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-234-0100
Provider Business Practice Location Address Fax Number:
409-654-2068
Provider Enumeration Date:
06/03/2006