Organization
IDAHO STREET MEDICAL CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
EDITH MARY ROE NP-BC (NURSE PRACTITIONER)
(208) 859-4103
Entity
Organization
Contact information
Practice address
126 W. IDAHO AVE, HOMEDALE, ID 83628-8362
(208) 337-7038
(208) 337-4652
Mailing address
24900 MARKET RD, PARMA, ID 83660-6723
(208) 722-7744
Taxonomy
Speciality
Code
Description
License number
State
261QH0100X
Health Service Clinic/Center
Primary
—
—
Other
Enumeration date
05/05/2020
Last updated
05/05/2020
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