Provider First Line Business Practice Location Address:
338 6TH ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-3320
Provider Business Practice Location Address Fax Number:
208-746-8717
Provider Enumeration Date:
06/14/2010