Provider First Line Business Practice Location Address:
816 MAIN STREET
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:
83501-1870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-791-6183
Provider Business Practice Location Address Fax Number:
949-404-8139
Provider Enumeration Date:
06/05/2019