Provider First Line Business Practice Location Address:
301 MAIN ST STE 106
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:
83501-1819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-718-5582
Provider Business Practice Location Address Fax Number:
208-281-3821
Provider Enumeration Date:
03/18/2024