Provider First Line Business Practice Location Address: 
114 E 3RD ST STE 8
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KIMBALL
    Provider Business Practice Location Address State Name: 
NE
    Provider Business Practice Location Address Postal Code: 
69145-1456
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
308-235-0262
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/02/2006