Provider First Line Business Practice Location Address:
312 MILLER 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:
83501-1944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-750-1802
Provider Business Practice Location Address Fax Number:
208-750-1803
Provider Enumeration Date:
10/18/2023