Provider First Line Business Practice Location Address:
1800 N 16TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51501-0123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-890-3915
Provider Business Practice Location Address Fax Number:
712-890-3919
Provider Enumeration Date:
07/11/2014