Provider First Line Business Practice Location Address:
602 13TH 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:
83501-2586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-675-7350
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2019