Provider First Line Business Practice Location Address: 
2000 70TH AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GREELEY
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80634-8626
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
970-350-2626
    Provider Business Practice Location Address Fax Number: 
970-350-2601
    Provider Enumeration Date: 
06/25/2012