Provider First Line Business Practice Location Address:
2315 8TH ST GRADE
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:
83501-7301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-1383
Provider Business Practice Location Address Fax Number:
208-298-0727
Provider Enumeration Date:
05/28/2006