Provider First Line Business Practice Location Address: 
1224 CENTER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GARDEN CITY
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67846-4643
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
620-275-1199
    Provider Business Practice Location Address Fax Number: 
620-275-1053
    Provider Enumeration Date: 
09/09/2016