Provider First Line Business Practice Location Address:
625 6TH AVE
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:
83501-9999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-8226
Provider Business Practice Location Address Fax Number:
208-746-2069
Provider Enumeration Date:
05/11/2006