Provider First Line Business Practice Location Address:
30736 HIGHWAY 200 STE 104
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:
83852-8701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-264-0644
Provider Business Practice Location Address Fax Number:
888-979-6134
Provider Enumeration Date:
12/18/2008