Provider First Line Business Practice Location Address: 
2650 JACKSON BLVD STE 19-A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RAPID CITY
    Provider Business Practice Location Address State Name: 
SD
    Provider Business Practice Location Address Postal Code: 
57702-3474
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
605-490-4229
    Provider Business Practice Location Address Fax Number: 
605-341-2072
    Provider Enumeration Date: 
08/31/2006