Provider First Line Business Practice Location Address:
450 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:
208-359-6419
Provider Business Practice Location Address Fax Number:
208-356-3111
Provider Enumeration Date:
10/05/2006