Provider First Line Business Practice Location Address:
633 MAIN STREET
Provider Second Line Business Practice Location Address:
B#1
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-724-0489
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2014