Provider First Line Business Practice Location Address:
3629 18TH 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:
83501-5972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-1971
Provider Business Practice Location Address Fax Number:
208-746-1458
Provider Enumeration Date:
10/10/2007