Provider First Line Business Practice Location Address: 
210 SOUTH 4TH ST.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FARMINGTON
    Provider Business Practice Location Address State Name: 
IA
    Provider Business Practice Location Address Postal Code: 
52626-0154
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
319-878-3367
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/14/2006