Provider First Line Business Practice Location Address: 
3825 W 9TH ST STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WATERLOO
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
50702-5909
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
319-234-4010
    Provider Business Practice Location Address Fax Number: 
319-234-0719
    Provider Enumeration Date: 
11/20/2006