Provider First Line Business Practice Location Address: 
211 W MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
STERLING
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80751-3168
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
970-522-4549
    Provider Business Practice Location Address Fax Number: 
970-522-4211
    Provider Enumeration Date: 
07/11/2012