Provider First Line Business Practice Location Address: 
14 S MAIN ST STE 1E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ABERDEEN
    Provider Business Practice Location Address State Name: 
SD
    Provider Business Practice Location Address Postal Code: 
57401-4189
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
605-225-1010
    Provider Business Practice Location Address Fax Number: 
605-725-8055
    Provider Enumeration Date: 
01/18/2023