Provider First Line Business Practice Location Address:
201 RIDGE ST
Provider Second Line Business Practice Location Address:
STE 314
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-322-0253
Provider Business Practice Location Address Fax Number:
712-322-5273
Provider Enumeration Date:
01/11/2007