Provider First Line Business Practice Location Address:
128 MAIN 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:
83501-4445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-305-5665
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2014