Provider First Line Business Practice Location Address:
215 1ST ST NE
Provider Second Line Business Practice Location Address:
BOX 178
Provider Business Practice Location Address City Name:
PRIMGHAR
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-957-0102
Provider Business Practice Location Address Fax Number:
712-957-0103
Provider Enumeration Date:
02/13/2007