Provider First Line Business Practice Location Address:
360 E. MAIN 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-356-5959
Provider Business Practice Location Address Fax Number:
208-356-5559
Provider Enumeration Date:
04/26/2007