Provider First Line Business Practice Location Address:
939 BRYDEN AVE
Provider Second Line Business Practice Location Address:
#2
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-5057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-0204
Provider Business Practice Location Address Fax Number:
208-746-0237
Provider Enumeration Date:
05/31/2005