Provider First Line Business Practice Location Address:
1139 ADDISON AVE E
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:
83301-5224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-2660
Provider Business Practice Location Address Fax Number:
208-736-3872
Provider Enumeration Date:
10/05/2007