Provider First Line Business Practice Location Address:
307 19TH ST STE A3
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:
83501-2086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-2948
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2007