Provider First Line Business Practice Location Address:
1300 KIMBERLY RD
Provider Second Line Business Practice Location Address:
SUITE 7B
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-7881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-736-1636
Provider Business Practice Location Address Fax Number:
208-735-1656
Provider Enumeration Date:
12/19/2005