Provider First Line Business Practice Location Address:
1367 LOCUST ST N
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:
83301-3477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-735-0700
Provider Business Practice Location Address Fax Number:
208-735-0900
Provider Enumeration Date:
09/17/2025