Provider First Line Business Practice Location Address:
700 E 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDA GROVE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51445-1601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-364-3504
Provider Business Practice Location Address Fax Number:
712-364-2539
Provider Enumeration Date:
08/16/2005