Provider First Line Business Practice Location Address: 
620 PINE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KEMMERER
    Provider Business Practice Location Address State Name: 
WY
    Provider Business Practice Location Address Postal Code: 
83101-3002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
307-877-4209
    Provider Business Practice Location Address Fax Number: 
307-877-6254
    Provider Enumeration Date: 
02/12/2007