Provider First Line Business Practice Location Address: 
715 E 14TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SIOUX FALLS
    Provider Business Practice Location Address State Name: 
SD
    Provider Business Practice Location Address Postal Code: 
57104-5151
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
605-271-0218
    Provider Business Practice Location Address Fax Number: 
605-271-0220
    Provider Enumeration Date: 
10/26/2006