Provider First Line Business Practice Location Address:
6750 AUGUSTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNERS FERRY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83805-8501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-7962
Provider Business Practice Location Address Fax Number:
208-267-8008
Provider Enumeration Date:
01/14/2008