Provider First Line Business Practice Location Address:
1012 W 36TH ST
Provider Second Line Business Practice Location Address:
SUITE #5
Provider Business Practice Location Address City Name:
SCOTTSBLUFF
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
69361-5007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-632-2551
Provider Business Practice Location Address Fax Number:
308-632-2725
Provider Enumeration Date:
11/29/2006