Provider First Line Business Practice Location Address:
404 N CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67855-5001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-356-2432
Provider Business Practice Location Address Fax Number:
620-356-4050
Provider Enumeration Date:
09/29/2008