Provider First Line Business Practice Location Address:
1132 BURRELL AVE
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:
83501-7101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-0231
Provider Business Practice Location Address Fax Number:
208-746-7462
Provider Enumeration Date:
03/16/2012