Provider First Line Business Practice Location Address: 
617 E ELM ST
    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: 
67401-8537
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-825-8221
    Provider Business Practice Location Address Fax Number: 
785-452-3294
    Provider Enumeration Date: 
01/28/2015