Provider First Line Business Practice Location Address: 
6079 NE 9TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DES MOINES
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
50313-1531
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
515-289-1981
    Provider Business Practice Location Address Fax Number: 
515-289-4051
    Provider Enumeration Date: 
10/26/2005