Provider First Line Business Practice Location Address: 
5080 FOSSIL BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FORT COLLINS
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80525-4034
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
970-494-4200
    Provider Business Practice Location Address Fax Number: 
970-613-4475
    Provider Enumeration Date: 
01/19/2018