Provider First Line Business Practice Location Address:
76 E 1ST S
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:
83440-1936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-709-9912
Provider Business Practice Location Address Fax Number:
208-932-1453
Provider Enumeration Date:
10/27/2009