Provider First Line Business Practice Location Address:
403 N BIRCH ST
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:
83352-5178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-751-1221
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2026