Provider First Line Business Practice Location Address:
501 S MAIN ST
Provider Second Line Business Practice Location Address:
STE 2B
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-6522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-323-4024
Provider Business Practice Location Address Fax Number:
712-323-0032
Provider Enumeration Date:
11/13/2006