Provider First Line Business Practice Location Address:
1107 EVANS ST
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:
67439-2553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-472-3454
Provider Business Practice Location Address Fax Number:
785-472-3644
Provider Enumeration Date:
06/14/2006