Provider First Line Business Practice Location Address:
859 S YELLOWSTONE HWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440-5293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-6433
Provider Business Practice Location Address Fax Number:
208-522-8443
Provider Enumeration Date:
09/26/2006