Provider First Line Business Practice Location Address:
731 POLE LINE RD
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:
83301-3036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-736-1725
Provider Business Practice Location Address Fax Number:
208-736-7318
Provider Enumeration Date:
01/26/2012