Provider First Line Business Practice Location Address:
484 EASTLAND DRIVE SOUTH
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:
83301-7958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-4112
Provider Business Practice Location Address Fax Number:
208-734-1514
Provider Enumeration Date:
01/11/2006