Provider First Line Business Practice Location Address: 
1 PADDOCK ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CRAWFORD
    Provider Business Practice Location Address State Name: 
NE
    Provider Business Practice Location Address Postal Code: 
69339-1143
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
308-665-1224
    Provider Business Practice Location Address Fax Number: 
308-665-2450
    Provider Enumeration Date: 
07/12/2006