Provider First Line Business Practice Location Address:
3326 4TH ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-4455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-2646
Provider Business Practice Location Address Fax Number:
208-746-8068
Provider Enumeration Date:
08/17/2006