Provider First Line Business Practice Location Address: 
8009 SHERIDAN LAKE RD
    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: 
57702-9041
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
701-650-1958
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/09/2013