Provider First Line Business Practice Location Address:
1630 23RD AVE STE 701
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:
83501-6345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-7055
Provider Business Practice Location Address Fax Number:
208-746-4899
Provider Enumeration Date:
08/31/2006