Provider First Line Business Practice Location Address:
2517 17TH ST 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:
83501-6311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-4373
Provider Business Practice Location Address Fax Number:
208-743-3369
Provider Enumeration Date:
10/17/2006