Provider First Line Business Practice Location Address:
4737 S AFTON PLACE SUITE A
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
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:
05/12/2014