Provider First Line Business Practice Location Address:
460 MAIN AVE SOUTH
Provider Second Line Business Practice Location Address:
SUITE C
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-7730
Provider Business Practice Location Address Fax Number:
208-735-8176
Provider Enumeration Date:
01/05/2007