Provider First Line Business Practice Location Address: 
1443 BECK AVENUE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CODY
    Provider Business Practice Location Address State Name: 
WY
    Provider Business Practice Location Address Postal Code: 
82414-3423
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
307-527-7811
    Provider Business Practice Location Address Fax Number: 
307-527-7396
    Provider Enumeration Date: 
09/13/2005