Provider First Line Business Practice Location Address:
30544 HIGHWAY 200 BLDG 300
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:
83852-5005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-946-7333
Provider Business Practice Location Address Fax Number:
208-625-2066
Provider Enumeration Date:
10/01/2024