Provider First Line Business Practice Location Address:
415 6TH 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:
83501-2431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-0516
Provider Business Practice Location Address Fax Number:
208-746-4989
Provider Enumeration Date:
06/01/2006