Provider First Line Business Practice Location Address:
6291 MAIN 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:
83805-8518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-0134
Provider Business Practice Location Address Fax Number:
208-561-7865
Provider Enumeration Date:
10/23/2012