Provider First Line Business Practice Location Address:
1537 24TH 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:
83501-6379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-331-4534
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2012