Provider First Line Business Practice Location Address:
2564 ELIZABETH BLVD
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:
83301-7508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-735-4160
Provider Business Practice Location Address Fax Number:
208-735-2426
Provider Enumeration Date:
12/04/2006