Provider First Line Business Practice Location Address:
823 16TH AVE
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:
83501-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-798-0200
Provider Business Practice Location Address Fax Number:
208-798-0201
Provider Enumeration Date:
11/21/2007