Provider First Line Business Practice Location Address:
533 S MIDDLETON RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
MIDDLETON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83644-6013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-585-6566
Provider Business Practice Location Address Fax Number:
208-585-6768
Provider Enumeration Date:
04/08/2015