Provider First Line Business Practice Location Address:
200 S 29TH ST
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:
51501-3449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-323-5801
Provider Business Practice Location Address Fax Number:
712-388-0553
Provider Enumeration Date:
10/28/2006