Provider First Line Business Practice Location Address: 
965 S 27TH ST
    Provider Second Line Business Practice Location Address: 
SUITE D
    Provider Business Practice Location Address City Name: 
LINCOLN
    Provider Business Practice Location Address State Name: 
NE
    Provider Business Practice Location Address Postal Code: 
68510-3140
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
402-477-3505
    Provider Business Practice Location Address Fax Number: 
402-573-6279
    Provider Enumeration Date: 
01/28/2010