Provider First Line Business Practice Location Address:
504 MAIN
Provider Second Line Business Practice Location Address:
SUITE 422
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-710-8171
Provider Business Practice Location Address Fax Number:
208-247-9247
Provider Enumeration Date:
04/16/2007