Provider First Line Business Practice Location Address:
307 19TH ST
Provider Second Line Business Practice Location Address:
SUITE A3
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-798-5132
Provider Business Practice Location Address Fax Number:
208-798-5143
Provider Enumeration Date:
08/06/2007