Provider First Line Business Practice Location Address:
133 WEST AVE A, ST. B
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:
83301-3392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-324-2004
Provider Business Practice Location Address Fax Number:
208-324-1154
Provider Enumeration Date:
05/23/2014