Provider First Line Business Practice Location Address:
6503 HARRISON 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:
83805-8619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-0203
Provider Business Practice Location Address Fax Number:
208-943-3161
Provider Enumeration Date:
03/25/2019