Provider First Line Business Practice Location Address:
3709 14TH 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-4373
Provider Business Practice Location Address Fax Number:
208-743-3369
Provider Enumeration Date:
03/10/2016