Provider First Line Business Practice Location Address: 
269A DEER PARK LANE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TELLURIDE
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
81435-0795
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
573-680-4818
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/24/2011