Provider First Line Business Practice Location Address:
202 2ND AVE N STE 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:
83301-6158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-308-4012
Provider Business Practice Location Address Fax Number:
208-732-6116
Provider Enumeration Date:
11/28/2006