Provider First Line Business Practice Location Address:
1010 BRYDEN AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-0455
Provider Business Practice Location Address Fax Number:
208-746-0688
Provider Enumeration Date:
08/24/2010