Provider First Line Business Practice Location Address:
2517 17TH ST
Provider Second Line Business Practice Location Address:
SUITE A
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:
208-746-1373
Provider Business Practice Location Address Fax Number:
208-746-9855
Provider Enumeration Date:
08/28/2006