Provider First Line Business Practice Location Address:
2227 W BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-322-8241
Provider Business Practice Location Address Fax Number:
712-322-8250
Provider Enumeration Date:
06/13/2006