Provider First Line Business Practice Location Address:
58 E 1ST N
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:
83440-1505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-709-0434
Provider Business Practice Location Address Fax Number:
208-269-1550
Provider Enumeration Date:
09/12/2012