Provider First Line Business Practice Location Address:
660 SHOSHONE ST E
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-6110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-732-3236
Provider Business Practice Location Address Fax Number:
208-732-3112
Provider Enumeration Date:
05/31/2006