Provider First Line Business Practice Location Address: 
1601 E 19TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHEYENNE
    Provider Business Practice Location Address State Name: 
WY
    Provider Business Practice Location Address Postal Code: 
82001-4928
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
307-635-0217
    Provider Business Practice Location Address Fax Number: 
307-634-6808
    Provider Enumeration Date: 
11/16/2006