Provider First Line Business Practice Location Address:
1209 3RD ST
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:
83501-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-710-7499
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/03/2025