Provider First Line Business Practice Location Address:
514 THAIN RD STE B
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:
83501-5533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-413-7353
Provider Business Practice Location Address Fax Number:
208-413-7338
Provider Enumeration Date:
06/27/2016