Provider First Line Business Practice Location Address:
428 6TH 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:
83501-2355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-9757
Provider Business Practice Location Address Fax Number:
208-965-8128
Provider Enumeration Date:
08/03/2011