Provider First Line Business Practice Location Address: 
634 EDDY AVE.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MISSOULA
    Provider Business Practice Location Address State Name: 
MT
    Provider Business Practice Location Address Postal Code: 
59812-6624
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
406-243-2778
    Provider Business Practice Location Address Fax Number: 
406-243-2726
    Provider Enumeration Date: 
05/01/2007