Provider First Line Business Practice Location Address:
117 W MAIN ST STE 1
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:
83440-1826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-0766
Provider Business Practice Location Address Fax Number:
208-359-9488
Provider Enumeration Date:
02/18/2025