Provider First Line Business Practice Location Address:
29 BLACK COAL RD
Provider Second Line Business Practice Location Address:
LABORATORY
Provider Business Practice Location Address City Name:
FORT WASHAKIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82514-0128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-332-7672
Provider Business Practice Location Address Fax Number:
307-332-7514
Provider Enumeration Date:
07/10/2010