Provider First Line Business Practice Location Address:
514 THAIN RD UNIT B
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:
83501-5533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-3398
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2025