Provider First Line Business Practice Location Address: 
440 S LINCOLN AVE
    Provider Second Line Business Practice Location Address: 
SUITE B1
    Provider Business Practice Location Address City Name: 
STEAMBOAT SPRINGS
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80487-8916
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
970-879-4327
    Provider Business Practice Location Address Fax Number: 
970-879-7783
    Provider Enumeration Date: 
05/20/2006