Provider First Line Business Practice Location Address: 
1 BULLDOG AVENUE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BALTIC
    Provider Business Practice Location Address State Name: 
SD
    Provider Business Practice Location Address Postal Code: 
57003-0309
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
605-529-5464
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/31/2006