Provider First Line Business Practice Location Address:
1604 2ND AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51501-3801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-332-7985
Provider Business Practice Location Address Fax Number:
712-322-7985
Provider Enumeration Date:
11/03/2006