Provider First Line Business Practice Location Address:
1203 IDAHO 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:
83501-1940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-848-8290
Provider Business Practice Location Address Fax Number:
208-848-8291
Provider Enumeration Date:
08/02/2012