Provider First Line Business Practice Location Address:
1239 POLE LINE RD E STE 314C
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:
83301-3469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-733-0601
Provider Business Practice Location Address Fax Number:
208-733-0604
Provider Enumeration Date:
03/30/2007