Provider First Line Business Practice Location Address:
520 N GREENWOOD STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-537-2020
Provider Business Practice Location Address Fax Number:
208-537-2010
Provider Enumeration Date:
09/09/2005