Provider First Line Business Practice Location Address: 
3300 SW 9TH STREET
    Provider Second Line Business Practice Location Address: 
STE 6A
    Provider Business Practice Location Address City Name: 
DES MOINES
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
50315-7666
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
515-244-0700
    Provider Business Practice Location Address Fax Number: 
515-244-6139
    Provider Enumeration Date: 
03/30/2006