Provider First Line Business Practice Location Address:
476999 US-95
Provider Second Line Business Practice Location Address:
WALMART SUPERCENTER
Provider Business Practice Location Address City Name:
PONDERAY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-4490
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2016