Provider First Line Business Practice Location Address:
230 EASTLAND DR UNIT 3
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:
83301-7439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-471-4270
Provider Business Practice Location Address Fax Number:
208-471-4266
Provider Enumeration Date:
09/22/2026