Provider First Line Business Practice Location Address: 
1625 MEDICAL CENTER PT
    Provider Second Line Business Practice Location Address: 
SUITE 180
    Provider Business Practice Location Address City Name: 
COLORADO SPRINGS
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80907-8731
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
719-667-1327
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/29/2016