Provider First Line Business Practice Location Address:
115 NORTHSTAR AVE
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:
83301-4073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-7676
Provider Business Practice Location Address Fax Number:
208-736-8378
Provider Enumeration Date:
06/28/2011