Provider First Line Business Practice Location Address:
115 S 29TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FORT DODGE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50501-2951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-573-7401
Provider Business Practice Location Address Fax Number:
515-576-8591
Provider Enumeration Date:
03/17/2006