Provider First Line Business Practice Location Address:
609 BRYDEN AVE STE B
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:
83501-5193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-413-6570
Provider Business Practice Location Address Fax Number:
208-413-9976
Provider Enumeration Date:
08/03/2010