Provider First Line Business Practice Location Address: 
345 LINCOLN AVE
    Provider Second Line Business Practice Location Address: 
SUITE 205
    Provider Business Practice Location Address City Name: 
STEAMBOAT SPRINGS
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80477
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
970-870-3484
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/20/2011