Provider First Line Business Practice Location Address:
200 SHC
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83460-2020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-496-1100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2006