Provider First Line Business Practice Location Address:
1322 WASHINGTON STREET NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-9036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-733-0740
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2012