Provider First Line Business Practice Location Address:
161 ERIC RD
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:
83352-5440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-358-5338
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2025