Provider First Line Business Practice Location Address:
6619 KANIKSU 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:
83805-7532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-2453
Provider Business Practice Location Address Fax Number:
208-267-7823
Provider Enumeration Date:
02/19/2016