Provider First Line Business Practice Location Address:
105 AND A HALF LOCUST ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BLAIRSTOWN
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-454-6455
Provider Business Practice Location Address Fax Number:
319-454-0091
Provider Enumeration Date:
05/22/2007