Provider First Line Business Practice Location Address:
939 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:
83501-5057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-1761
Provider Business Practice Location Address Fax Number:
208-746-8042
Provider Enumeration Date:
12/10/2013