Provider First Line Business Practice Location Address:
1002 W WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POLK CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50226-2132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-984-6411
Provider Business Practice Location Address Fax Number:
515-984-9294
Provider Enumeration Date:
10/24/2006