Provider First Line Business Practice Location Address:
720 16TH AVE STE 3
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:
83501-3768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-7766
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2006