Provider First Line Business Practice Location Address:
3315 8TH ST
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:
83501-4966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-9543
Provider Business Practice Location Address Fax Number:
208-743-3945
Provider Enumeration Date:
06/23/2008