Provider First Line Business Practice Location Address:
217 N 2ND E
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:
83440-1621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-359-6127
Provider Business Practice Location Address Fax Number:
208-359-6127
Provider Enumeration Date:
07/30/2006