Provider First Line Business Practice Location Address:
1020 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83644-5270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-585-3932
Provider Business Practice Location Address Fax Number:
208-565-2218
Provider Enumeration Date:
12/05/2019