Provider First Line Business Practice Location Address:
6426 KOOTENAI ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
BONNERS FERRY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83805-8620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-745-2700
Provider Business Practice Location Address Fax Number:
208-598-7990
Provider Enumeration Date:
02/28/2023