Provider First Line Business Practice Location Address:
608 SHOUP AVE W
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:
83301-4550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-455-2235
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2026