Provider First Line Business Practice Location Address:
440 FAIRFIELD 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:
83301-6129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-1430
Provider Business Practice Location Address Fax Number:
208-734-0588
Provider Enumeration Date:
11/01/2005