Provider First Line Business Practice Location Address:
124 NEW 6TH 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:
83501-2133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-5580
Provider Business Practice Location Address Fax Number:
208-746-5456
Provider Enumeration Date:
09/12/2012