Provider First Line Business Practice Location Address:
1074 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:
208-989-9909
Provider Business Practice Location Address Fax Number:
208-266-9234
Provider Enumeration Date:
06/18/2015