Provider First Line Business Practice Location Address:
313 D ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-1894
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-798-8070
Provider Business Practice Location Address Fax Number:
208-798-8068
Provider Enumeration Date:
04/23/2007