Provider First Line Business Practice Location Address:
1630 23RD AVE
Provider Second Line Business Practice Location Address:
STES. 302 & 401, BLDG. 2
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:
702-341-3164
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2006