Provider First Line Business Practice Location Address:
3510 12TH STREET
Provider Second Line Business Practice Location Address:
SUITE #600
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-798-7955
Provider Business Practice Location Address Fax Number:
208-798-7957
Provider Enumeration Date:
02/17/2012