Provider First Line Business Practice Location Address:
2315 8TH ST GRADE
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:
83501-7301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-455-8820
Provider Business Practice Location Address Fax Number:
509-227-7070
Provider Enumeration Date:
05/20/2006