Provider First Line Business Practice Location Address:
PO BOX 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:
83501-0182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-799-4440
Provider Business Practice Location Address Fax Number:
208-799-5171
Provider Enumeration Date:
03/17/2016