Provider First Line Business Practice Location Address: 
2715 25TH ST S
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLINTON
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
52732
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
563-243-0330
    Provider Business Practice Location Address Fax Number: 
563-243-0334
    Provider Enumeration Date: 
10/31/2006