Provider First Line Business Practice Location Address:
321 17TH 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-3398
Provider Business Practice Location Address Fax Number:
208-798-1601
Provider Enumeration Date:
05/18/2018