Provider First Line Business Practice Location Address:
408 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:
83440-1874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-5656
Provider Business Practice Location Address Fax Number:
208-534-7450
Provider Enumeration Date:
12/02/2025