Provider First Line Business Practice Location Address:
30544 HIGHWAY 200
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-5005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-304-3128
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2014