Provider First Line Business Practice Location Address: 
321 E 12TH ST RM 175
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DES MOINES
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
50319-0075
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
515-281-5604
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/06/2006