Provider First Line Business Practice Location Address:
200 2ND AVE N
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:
83301-6172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-761-4179
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2026