Provider First Line Business Practice Location Address: 
3002 NORDIC CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SIOUX CITY
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
51104-2840
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
712-253-7426
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/20/2006