Provider First Line Business Practice Location Address: 
2230 33RD ST
    Provider Second Line Business Practice Location Address: 
SUITE 8
    Provider Business Practice Location Address City Name: 
SPIRIT LAKE
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
51360-7632
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
712-336-1600
    Provider Business Practice Location Address Fax Number: 
712-336-1602
    Provider Enumeration Date: 
11/14/2008