Provider First Line Business Practice Location Address:
1630 23RD AVE
Provider Second Line Business Practice Location Address:
BLDG 301
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:
208-790-3083
Provider Business Practice Location Address Fax Number:
208-798-7177
Provider Enumeration Date:
10/14/2005