Provider First Line Business Practice Location Address: 
318 E MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CORTEZ
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
81321-3238
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
970-739-8367
    Provider Business Practice Location Address Fax Number: 
970-565-8103
    Provider Enumeration Date: 
10/21/2009