Provider First Line Business Practice Location Address:
476653 HIGHWAY 95 STE 1
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:
83852-9816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-6771
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2026