Provider First Line Business Practice Location Address:
911 PREACHER CREEK 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:
83352-5061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-886-2565
Provider Business Practice Location Address Fax Number:
208-886-2153
Provider Enumeration Date:
04/02/2009