Provider First Line Business Practice Location Address:
324 5TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-5025
Provider Business Practice Location Address Fax Number:
208-746-4946
Provider Enumeration Date:
04/11/2007