Provider First Line Business Practice Location Address: 
8204 HIGHWAY 789
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LANDER
    Provider Business Practice Location Address State Name: 
WY
    Provider Business Practice Location Address Postal Code: 
82520-2941
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
307-335-6731
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/17/2009