Provider First Line Business Practice Location Address: 
3286 53RD AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLUMBUS
    Provider Business Practice Location Address State Name: 
NE
    Provider Business Practice Location Address Postal Code: 
68601-1516
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
402-564-1124
    Provider Business Practice Location Address Fax Number: 
402-563-0710
    Provider Enumeration Date: 
06/14/2011