Provider First Line Business Practice Location Address:
121 W. MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-464-3165
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2007