Provider First Line Business Practice Location Address:
222 SOUTHWAY AVE STE 2A
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:
83501-2703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-798-4818
Provider Business Practice Location Address Fax Number:
208-798-8711
Provider Enumeration Date:
05/26/2006