Provider First Line Business Practice Location Address:
50 S HIGHWAY 93
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:
83352-5337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-942-3311
Provider Business Practice Location Address Fax Number:
801-495-5303
Provider Enumeration Date:
08/29/2012