Provider First Line Business Practice Location Address:
307 SAINT JOHNS WAY
Provider Second Line Business Practice Location Address:
SUITE 17
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-9644
Provider Business Practice Location Address Fax Number:
208-746-0782
Provider Enumeration Date:
07/25/2006