Provider First Line Business Practice Location Address:
504 MAIN ST STE 132
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:
83501-1869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-289-1227
Provider Business Practice Location Address Fax Number:
208-289-1227
Provider Enumeration Date:
03/12/2013