Provider First Line Business Practice Location Address:
58457 HIGHWAY 12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWCASTLE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68757-6056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-870-1836
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2026