Provider First Line Business Practice Location Address:
415 6TH ST
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:
512-730-3056
Provider Business Practice Location Address Fax Number:
888-730-1925
Provider Enumeration Date:
12/17/2018