Provider First Line Business Practice Location Address: 
2120 8TH AVE NE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ABERDEEN
    Provider Business Practice Location Address State Name: 
SD
    Provider Business Practice Location Address Postal Code: 
57401-3242
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
605-725-4772
    Provider Business Practice Location Address Fax Number: 
605-725-4777
    Provider Enumeration Date: 
07/20/2018