Provider First Line Business Practice Location Address:
61 E HIGHWAY 24
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOSHONE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83352-5338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-886-2381
Provider Business Practice Location Address Fax Number:
208-886-2038
Provider Enumeration Date:
03/06/2008