Provider First Line Business Practice Location Address:
2335 MAIN ST
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:
83501-3242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-791-0129
Provider Business Practice Location Address Fax Number:
208-743-1170
Provider Enumeration Date:
01/21/2019