Provider First Line Business Practice Location Address:
1630 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE 701
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-6350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-3998
Provider Business Practice Location Address Fax Number:
208-746-4879
Provider Enumeration Date:
10/17/2005