Provider First Line Business Practice Location Address:
500 8TH AVE
Provider Second Line Business Practice Location Address:
SAM GLENN COMPLEX 205
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-792-2251
Provider Business Practice Location Address Fax Number:
208-792-2882
Provider Enumeration Date:
11/26/2014