Provider First Line Business Practice Location Address:
2102 NEZ PERCE DR
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:
83501-4116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-4434
Provider Business Practice Location Address Fax Number:
208-743-9422
Provider Enumeration Date:
09/13/2018