Provider First Line Business Practice Location Address:
106 E 1ST NORTH
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:
83440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-5600
Provider Business Practice Location Address Fax Number:
208-419-0202
Provider Enumeration Date:
10/05/2012