Provider First Line Business Practice Location Address:
625 POLE LINE RD W STE 2A
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:
83301-4270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-814-8740
Provider Business Practice Location Address Fax Number:
208-814-8955
Provider Enumeration Date:
06/27/2006