Provider First Line Business Practice Location Address:
1630 23RD AVE STE 301B
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:
83501-6357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-5101
Provider Business Practice Location Address Fax Number:
208-746-5282
Provider Enumeration Date:
07/02/2007