Provider First Line Business Practice Location Address:
691 SHOSHONE ST 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:
83301-6154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-733-1067
Provider Business Practice Location Address Fax Number:
208-733-7597
Provider Enumeration Date:
10/31/2006