Provider First Line Business Practice Location Address:
511 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:
83644-5545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-323-9600
Provider Business Practice Location Address Fax Number:
208-466-5359
Provider Enumeration Date:
06/10/2026