Provider First Line Business Practice Location Address: 
100 E. COLLEGE DRIVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLBY
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67701
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-460-4868
    Provider Business Practice Location Address Fax Number: 
785-460-4870
    Provider Enumeration Date: 
09/02/2011