Provider First Line Business Practice Location Address:
3407 12TH STREET C
Provider Second Line Business Practice Location Address:
3407 12TH STREET C
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-790-0132
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2020