Provider First Line Business Practice Location Address: 
606 E GARFIELD AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GETTYSBURG
    Provider Business Practice Location Address State Name: 
SD
    Provider Business Practice Location Address Postal Code: 
57442-1325
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
605-765-2480
    Provider Business Practice Location Address Fax Number: 
605-765-2704
    Provider Enumeration Date: 
01/27/2006