Provider First Line Business Practice Location Address:
450 THAIN RD STE A
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:
83501-5300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-816-8836
Provider Business Practice Location Address Fax Number:
208-621-2995
Provider Enumeration Date:
12/14/2006