Provider First Line Business Practice Location Address:
1502 LOCUST ST N STE 600
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:
83301-4164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-6091
Provider Business Practice Location Address Fax Number:
208-734-4654
Provider Enumeration Date:
02/17/2006