Provider First Line Business Practice Location Address:
706 17TH AVE #104
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-816-4608
Provider Business Practice Location Address Fax Number:
208-816-4608
Provider Enumeration Date:
02/12/2008