Provider First Line Business Practice Location Address: 
799 E 3RD ST STE 1
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DURANGO
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
81301-5793
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
970-375-2369
    Provider Business Practice Location Address Fax Number: 
970-375-9054
    Provider Enumeration Date: 
12/16/2014