Provider First Line Business Practice Location Address:
202 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PORTE CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50651-1234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-342-2232
Provider Business Practice Location Address Fax Number:
319-342-3770
Provider Enumeration Date:
05/27/2005