Provider First Line Business Practice Location Address:
2120 THAIN GRADE
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:
83501-4105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-1044
Provider Business Practice Location Address Fax Number:
208-746-0744
Provider Enumeration Date:
08/02/2012