Provider First Line Business Practice Location Address:
450 THAIN RD
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-5300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-0150
Provider Business Practice Location Address Fax Number:
208-743-5358
Provider Enumeration Date:
04/17/2007