Provider First Line Business Practice Location Address:
1239 POLELINE RD E STE 312C
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:
83301-3469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-736-2924
Provider Business Practice Location Address Fax Number:
208-736-3340
Provider Enumeration Date:
01/28/2011