Provider First Line Business Practice Location Address: 
803 S VIVIAN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WAUSA
    Provider Business Practice Location Address State Name: 
NE
    Provider Business Practice Location Address Postal Code: 
68786-2046
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
402-586-2890
    Provider Business Practice Location Address Fax Number: 
402-586-2945
    Provider Enumeration Date: 
11/20/2006