Provider First Line Business Practice Location Address:
222 SOUTHWAY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-1333
Provider Business Practice Location Address Fax Number:
208-746-8090
Provider Enumeration Date:
01/30/2007