Provider First Line Business Practice Location Address: 
448 E HIGHWAY 47
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GIRARD
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66743-0172
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
620-724-6058
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/22/2008