Provider First Line Business Practice Location Address:
1630 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE 901B
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-6350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-298-0103
Provider Business Practice Location Address Fax Number:
208-746-8566
Provider Enumeration Date:
09/06/2005