Provider First Line Business Practice Location Address:
1503 19TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTTSBLUFF
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69361-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-249-5520
Provider Business Practice Location Address Fax Number:
308-275-2042
Provider Enumeration Date:
10/21/2025