Provider First Line Business Practice Location Address:
419 22ND AVE
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:
83501-3812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-9404
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2023