Provider First Line Business Practice Location Address:
201 S 1ST AVE E
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:
83644-5809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-585-6311
Provider Business Practice Location Address Fax Number:
208-585-6221
Provider Enumeration Date:
01/20/2006