Provider First Line Business Practice Location Address:
HC 1 BOX 55
Provider Second Line Business Practice Location Address:
COUNTY RD V-3
Provider Business Practice Location Address City Name:
MANTER
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67862-9411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-592-2061
Provider Business Practice Location Address Fax Number:
620-592-2061
Provider Enumeration Date:
10/02/2007