Provider First Line Business Practice Location Address:
1331 G 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:
83501-1964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-9616
Provider Business Practice Location Address Fax Number:
833-963-2105
Provider Enumeration Date:
05/19/2020