Provider First Line Business Practice Location Address: 
1601 CORNHUSKER DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SOUTH SIOUX CITY
    Provider Business Practice Location Address State Name: 
NE
    Provider Business Practice Location Address Postal Code: 
68776-3924
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
402-494-1498
    Provider Business Practice Location Address Fax Number: 
402-494-1594
    Provider Enumeration Date: 
07/29/2011