Provider First Line Business Practice Location Address:
381 EAST 4TH NORTH
Provider Second Line Business Practice Location Address:
SUITE 200
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:
208-359-2300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2006