Provider First Line Business Practice Location Address:
1321 2ND AVENUE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT DODGE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50501-4925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-576-4156
Provider Business Practice Location Address Fax Number:
515-576-6998
Provider Enumeration Date:
02/28/2006