Provider First Line Business Practice Location Address:
556 TREJO ST
Provider Second Line Business Practice Location Address:
SUITE B
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:
208-359-2263
Provider Business Practice Location Address Fax Number:
208-359-2042
Provider Enumeration Date:
01/25/2007