Provider First Line Business Practice Location Address:
739 BRYDEN AVE STE A
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:
83501-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-5830
Provider Business Practice Location Address Fax Number:
208-743-5831
Provider Enumeration Date:
04/04/2011