Provider First Line Business Practice Location Address:
531 4TH 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:
83501-2450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-4393
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2006