Provider First Line Business Practice Location Address: 
6040 S 58TH ST STE C
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LINCOLN
    Provider Business Practice Location Address State Name: 
NE
    Provider Business Practice Location Address Postal Code: 
68516-3695
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
402-421-1142
    Provider Business Practice Location Address Fax Number: 
402-421-1167
    Provider Enumeration Date: 
10/09/2017