Provider First Line Business Practice Location Address:
30410 HIGHWAY 200 STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-9601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-3211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2026