Provider First Line Business Practice Location Address:
459 LOCUST ST N STE 110
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:
83301-7324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-8263
Provider Business Practice Location Address Fax Number:
208-938-5306
Provider Enumeration Date:
11/10/2006