Provider First Line Business Practice Location Address: 
1102 BECK AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CODY
    Provider Business Practice Location Address State Name: 
WY
    Provider Business Practice Location Address Postal Code: 
82414-3624
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
307-587-8889
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/24/2007