Provider First Line Business Practice Location Address: 
957 S MANHATTAN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MANHATTAN
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66502-9404
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-564-2747
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/02/2006