Provider First Line Business Practice Location Address: 
600 MARSHALL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SUPERIOR
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80027-9730
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
720-587-1001
    Provider Business Practice Location Address Fax Number: 
720-587-1005
    Provider Enumeration Date: 
01/29/2015