Provider First Line Business Practice Location Address:
255 N 30TH ST
Provider Second Line Business Practice Location Address:
IVINSON MEMORIAL HOSPITAL, SUITE 5B SPECIALTY CLINIC
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82072-5140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-460-8570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2008