Provider First Line Business Practice Location Address:
476999 HIGHWAY 95
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:
83852-9738
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:
208-265-0794
Provider Enumeration Date:
07/21/2014