Provider First Line Business Practice Location Address:
808 EASTLAND DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-6813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-539-5090
Provider Business Practice Location Address Fax Number:
208-878-3424
Provider Enumeration Date:
10/03/2012