Provider First Line Business Practice Location Address:
2691 S 2000 W STE 3
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:
83440-4089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-656-7444
Provider Business Practice Location Address Fax Number:
208-656-7464
Provider Enumeration Date:
08/21/2026