Provider First Line Business Practice Location Address:
476864 HIGHWAY 95
Provider Second Line Business Practice Location Address:
SUITE #3
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-946-0984
Provider Business Practice Location Address Fax Number:
208-246-4995
Provider Enumeration Date:
10/15/2009