Provider First Line Business Practice Location Address: 
165 W 3RD ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOISINGTON
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67544-2201
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
620-653-4134
    Provider Business Practice Location Address Fax Number: 
620-653-4073
    Provider Enumeration Date: 
09/17/2009