Provider First Line Business Practice Location Address:
36 PROFESSIONAL PLZ
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-3621
Provider Business Practice Location Address Fax Number:
208-356-5743
Provider Enumeration Date:
03/12/2008