Provider First Line Business Practice Location Address:
762 NORTH COLLEGE ROAD
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:
83301-3382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-733-0505
Provider Business Practice Location Address Fax Number:
208-734-0766
Provider Enumeration Date:
08/31/2005