Provider First Line Business Practice Location Address:
1630 23RD AVE
Provider Second Line Business Practice Location Address:
SUITE 1001
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-6350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-553-4780
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2013