Provider First Line Business Practice Location Address:
1515 S NEWCASTLE RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68801-0741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-390-9103
Provider Business Practice Location Address Fax Number:
308-382-5315
Provider Enumeration Date:
12/27/2006