Provider First Line Business Practice Location Address:
77 SOUTHWAY AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-798-4427
Provider Business Practice Location Address Fax Number:
208-743-4807
Provider Enumeration Date:
02/23/2017