Provider First Line Business Practice Location Address:
111 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:
83644-5637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-899-2856
Provider Business Practice Location Address Fax Number:
208-585-6431
Provider Enumeration Date:
03/08/2006