Provider First Line Business Practice Location Address:
122 N DOUGLAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLSWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67439-3214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-472-4081
Provider Business Practice Location Address Fax Number:
785-472-3851
Provider Enumeration Date:
01/18/2007