Provider First Line Business Practice Location Address: 
50 W 2ND ST LOT 12
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LOVELL
    Provider Business Practice Location Address State Name: 
WY
    Provider Business Practice Location Address Postal Code: 
82431-1701
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
307-202-2489
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/28/2012