Provider First Line Business Practice Location Address:
2167 COOLWATER ST
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:
83301-4798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-731-4592
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2026