Provider First Line Business Practice Location Address: 
2707 VINE
    Provider Second Line Business Practice Location Address: 
SUITE 6
    Provider Business Practice Location Address City Name: 
HAYS
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67601
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-625-7117
    Provider Business Practice Location Address Fax Number: 
785-650-0040
    Provider Enumeration Date: 
09/25/2006