Provider First Line Business Practice Location Address:
1201 EAST HIGHWAY 18
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE RIDGE
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-867-3003
Provider Business Practice Location Address Fax Number:
605-867-3305
Provider Enumeration Date:
05/04/2010