Provider First Line Business Practice Location Address:
6615 COMMANCHE
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-1718
Provider Business Practice Location Address Fax Number:
208-263-7739
Provider Enumeration Date:
03/28/2012