Provider First Line Business Practice Location Address:
310 N 2ND E
Provider Second Line Business Practice Location Address:
SUITE 128
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-709-6257
Provider Business Practice Location Address Fax Number:
208-356-5675
Provider Enumeration Date:
07/29/2013