Provider First Line Business Practice Location Address:
27 K 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:
83440-1441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-4845
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2011