Provider First Line Business Practice Location Address:
2841 JUNIPER DR STE 2
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:
83501-4719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-848-9001
Provider Business Practice Location Address Fax Number:
208-848-9002
Provider Enumeration Date:
09/18/2015