Provider First Line Business Practice Location Address: 
3116 WILLET DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LARAMIE
    Provider Business Practice Location Address State Name: 
WY
    Provider Business Practice Location Address Postal Code: 
82072
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
970-493-7733
    Provider Business Practice Location Address Fax Number: 
970-493-8745
    Provider Enumeration Date: 
12/06/2007