Provider First Line Business Practice Location Address:
336 WARNER DR STE 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:
83501-4441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-391-9311
Provider Business Practice Location Address Fax Number:
208-473-7304
Provider Enumeration Date:
12/16/2022