Provider First Line Business Practice Location Address: 
1314 3RD AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEBRASKA CITY
    Provider Business Practice Location Address State Name: 
NE
    Provider Business Practice Location Address Postal Code: 
68410-1930
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
402-873-8918
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/25/2013