Provider First Line Business Practice Location Address:
515 E 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:
51503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-322-1407
Provider Business Practice Location Address Fax Number:
712-322-6833
Provider Enumeration Date:
12/15/2006