Provider First Line Business Practice Location Address:
1002 IDAHO ST
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:
83501-1938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-7661
Provider Business Practice Location Address Fax Number:
208-746-0811
Provider Enumeration Date:
09/23/2013