Provider First Line Business Practice Location Address:
1250 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:
83501-1965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-799-5219
Provider Business Practice Location Address Fax Number:
208-799-6578
Provider Enumeration Date:
09/09/2013