Provider First Line Business Practice Location Address:
5565 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:
83202-2126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-478-9344
Provider Business Practice Location Address Fax Number:
208-478-9368
Provider Enumeration Date:
04/17/2007