Provider First Line Business Practice Location Address:
4342 I-80 SERVICE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURNS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82053-9802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-256-6792
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2026