Provider First Line Business Practice Location Address: 
559 E PIKES PEAK AVE
    Provider Second Line Business Practice Location Address: 
STE 203
    Provider Business Practice Location Address City Name: 
COLORADO SPRINGS
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80903
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
719-473-9222
    Provider Business Practice Location Address Fax Number: 
719-473-0133
    Provider Enumeration Date: 
10/03/2006