Provider First Line Business Practice Location Address:
1910 IDAHO STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-4022
Provider Business Practice Location Address Fax Number:
208-746-0170
Provider Enumeration Date:
10/28/2005