Provider First Line Business Practice Location Address: 
101 W COLLEGE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WASHINGTON
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66968-1910
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-325-2261
    Provider Business Practice Location Address Fax Number: 
785-325-2771
    Provider Enumeration Date: 
09/16/2009