Provider First Line Business Practice Location Address:
676 SHOUP AVE W STE 14
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:
83301-4615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-392-1829
Provider Business Practice Location Address Fax Number:
888-915-0796
Provider Enumeration Date:
03/30/2007