Provider First Line Business Practice Location Address:
174 ASH STREET NORTH
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:
83301-5232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-3148
Provider Business Practice Location Address Fax Number:
208-736-3907
Provider Enumeration Date:
08/24/2006