Provider First Line Business Practice Location Address:
523 1/2 MAIN ST # 7
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:
83501-1870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-413-9973
Provider Business Practice Location Address Fax Number:
208-413-9976
Provider Enumeration Date:
04/10/2011