Provider First Line Business Practice Location Address:
2116 12TH AVE
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:
83501-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-0662
Provider Business Practice Location Address Fax Number:
208-743-0677
Provider Enumeration Date:
12/29/2014