Provider First Line Business Practice Location Address:
1522 17TH 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:
83501-3652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-8416
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2020