Provider First Line Business Practice Location Address:
746 N COLLEGE RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-3486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-814-7271
Provider Business Practice Location Address Fax Number:
208-814-7290
Provider Enumeration Date:
08/11/2010