Provider First Line Business Practice Location Address:
338 6TH ST STE 101
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:
83501-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
120-884-8830
Provider Business Practice Location Address Fax Number:
509-444-7806
Provider Enumeration Date:
10/15/2007