Provider First Line Business Practice Location Address:
232 SOUTH MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUSK
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82225-0690
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-334-3132
Provider Business Practice Location Address Fax Number:
307-334-2026
Provider Enumeration Date:
09/13/2006