Provider First Line Business Practice Location Address:
307 ST. JOHNS WAY
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-7612
Provider Business Practice Location Address Fax Number:
208-746-4802
Provider Enumeration Date:
10/20/2006