Provider First Line Business Practice Location Address:
1630 23RD AVE BLDG 2
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:
83501-6350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-7784
Provider Business Practice Location Address Fax Number:
208-798-8652
Provider Enumeration Date:
02/08/2022