Provider First Line Business Practice Location Address:
678 SOUTHWAY 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:
83501-3783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-1418
Provider Business Practice Location Address Fax Number:
208-746-4123
Provider Enumeration Date:
05/26/2020