Provider First Line Business Practice Location Address: 
2327 70TH STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
URBANDALE
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
50322
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
515-270-2242
    Provider Business Practice Location Address Fax Number: 
515-777-1950
    Provider Enumeration Date: 
07/10/2014