Provider First Line Business Practice Location Address:
1502 LOCUST ST N STE 100
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:
83301-4163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-933-2540
Provider Business Practice Location Address Fax Number:
208-933-2541
Provider Enumeration Date:
01/30/2017