Provider First Line Business Practice Location Address:
111 MAIN 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:
83501-2141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-791-4925
Provider Business Practice Location Address Fax Number:
509-758-1028
Provider Enumeration Date:
01/30/2008