Provider First Line Business Practice Location Address:
1630 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE 801
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-6345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-298-3002
Provider Business Practice Location Address Fax Number:
208-743-3369
Provider Enumeration Date:
10/17/2005