Provider First Line Business Practice Location Address:
3316 1/2 4TH ST STE 4B
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:
83501-4460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-413-7279
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2023