Provider First Line Business Practice Location Address:
476864 HWY 95 N
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852-9737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-0142
Provider Business Practice Location Address Fax Number:
208-265-0185
Provider Enumeration Date:
03/27/2007