Provider First Line Business Practice Location Address:
SCH 100
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:
83460-2010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-456-1300
Provider Business Practice Location Address Fax Number:
208-456-1306
Provider Enumeration Date:
12/19/2005