Provider First Line Business Practice Location Address: 
1610 29TH AVENUE PL
    Provider Second Line Business Practice Location Address: 
SUITE 200
    Provider Business Practice Location Address City Name: 
GREELEY
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80634-6813
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
970-352-8311
    Provider Business Practice Location Address Fax Number: 
970-356-9884
    Provider Enumeration Date: 
01/17/2008