Organization
IDAHO STREET MEDICAL CLINIC
Active
Other names
Idaho Street Medical Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
EDITH ROE NURSE PRACTITIONER (PRESIDENT)
(208) 859-4103
Entity
Organization
Contact information
Practice address
126 IDAHO AVE., HOMEDALE, ID 83628-8362
(208) 859-4103
Mailing address
PO BOX 37, HOMEDALE, ID 83628-0037
(208) 337-3898
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
—
Other
Enumeration date
03/07/2019
Last updated
03/07/2019
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