Provider First Line Business Practice Location Address:
3428 5TH 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:
83501-4538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-552-6674
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2023