Provider First Line Business Practice Location Address: 
123 E 3RD ST STE 2
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OTTUMWA
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
52501-2937
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
641-682-8145
    Provider Business Practice Location Address Fax Number: 
641-682-8857
    Provider Enumeration Date: 
01/12/2006