Provider First Line Business Practice Location Address:
1024 F STREET
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:
83501-5530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-305-8981
Provider Business Practice Location Address Fax Number:
480-400-4383
Provider Enumeration Date:
03/09/2021