Provider First Line Business Practice Location Address:
7174 MAIN ST.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BONNERS FERRY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83805-8740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-0936
Provider Business Practice Location Address Fax Number:
208-267-0936
Provider Enumeration Date:
03/29/2011