Provider First Line Business Practice Location Address:
6040 S 58TH ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68516-3695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-421-1142
Provider Business Practice Location Address Fax Number:
402-421-1167
Provider Enumeration Date:
02/16/2011