Provider First Line Business Practice Location Address:
190 W BURNSIDE
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
CHUBBUCK
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-417-8842
Provider Business Practice Location Address Fax Number:
833-728-0327
Provider Enumeration Date:
09/29/2014