Provider First Line Business Practice Location Address:
436 CALIFORNIA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66748-1383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-473-2734
Provider Business Practice Location Address Fax Number:
620-431-7741
Provider Enumeration Date:
01/08/2007