Provider First Line Business Practice Location Address: 
6709 S MINNESOTA AVENUE
    Provider Second Line Business Practice Location Address: 
SUITE 105
    Provider Business Practice Location Address City Name: 
SIOUX FALLS
    Provider Business Practice Location Address State Name: 
SD
    Provider Business Practice Location Address Postal Code: 
57108-2593
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
605-338-3938
    Provider Business Practice Location Address Fax Number: 
605-338-1693
    Provider Enumeration Date: 
06/24/2011