Provider First Line Business Practice Location Address:
1014 BURRELL AVE
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:
83501-5472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-4558
Provider Business Practice Location Address Fax Number:
208-746-7657
Provider Enumeration Date:
01/24/2007