Provider First Line Business Practice Location Address:
532 BRYDEN AVE
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:
83501-4445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-798-5168
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/18/2006