Provider First Line Business Practice Location Address:
621 19TH 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:
83501-3893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-791-8582
Provider Business Practice Location Address Fax Number:
208-792-2183
Provider Enumeration Date:
03/30/2012