Provider First Line Business Practice Location Address:
130 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84320-1501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-512-6152
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2015