Provider First Line Business Practice Location Address:
307 SAINT JOHNS WAY
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-0133
Provider Business Practice Location Address Fax Number:
208-746-0134
Provider Enumeration Date:
08/21/2006