Provider First Line Business Practice Location Address:
130 W MAIN ST
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:
83440-1827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-4132
Provider Business Practice Location Address Fax Number:
208-356-9340
Provider Enumeration Date:
03/21/2007