Provider First Line Business Practice Location Address:
3316 1/2 4TH ST
Provider Second Line Business Practice Location Address:
SUITE 4A
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-4460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-780-7822
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2011