Provider First Line Business Practice Location Address: 
1508 E IRON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SALINA
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67401-3236
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-823-3654
    Provider Business Practice Location Address Fax Number: 
785-827-1280
    Provider Enumeration Date: 
05/25/2006