Provider First Line Business Practice Location Address:
615 21ST 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:
83501-3285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-413-7062
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2015