Provider First Line Business Practice Location Address:
325 MARTIN ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-4563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-732-7447
Provider Business Practice Location Address Fax Number:
208-733-5940
Provider Enumeration Date:
10/20/2006