Provider First Line Business Practice Location Address:
526 SHOUP AVE W STE M
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:
83301-5050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-0446
Provider Business Practice Location Address Fax Number:
208-734-1502
Provider Enumeration Date:
02/21/2007