Provider First Line Business Practice Location Address:
532 THAIN RD
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:
83501-5533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-780-3038
Provider Business Practice Location Address Fax Number:
208-693-1667
Provider Enumeration Date:
03/21/2017