Provider First Line Business Practice Location Address:
3510 12TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-5575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-8249
Provider Business Practice Location Address Fax Number:
208-750-1897
Provider Enumeration Date:
11/15/2006