Provider First Line Business Practice Location Address:
RT 4 6522 TAMARACK LN
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:
83805-9805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-3187
Provider Business Practice Location Address Fax Number:
208-267-3251
Provider Enumeration Date:
02/28/2007