Provider First Line Business Practice Location Address:
859 S YELLOWSTONE HWY
Provider Second Line Business Practice Location Address:
SUITE #1202
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440-5293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-552-5439
Provider Business Practice Location Address Fax Number:
208-552-5440
Provider Enumeration Date:
05/23/2007