Provider First Line Business Practice Location Address:
3316 4TH ST
Provider Second Line Business Practice Location Address:
BLDG 3
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-4405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-0458
Provider Business Practice Location Address Fax Number:
208-743-6020
Provider Enumeration Date:
01/07/2013