Provider First Line Business Practice Location Address:
320 11TH 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:
83501-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-305-8493
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2006