Provider First Line Business Practice Location Address:
1120 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68376-6019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-862-3280
Provider Business Practice Location Address Fax Number:
402-862-3284
Provider Enumeration Date:
05/28/2006