Provider First Line Business Practice Location Address: 
2936 GEORGIA AVE
    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: 
67401-7948
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-825-6954
    Provider Business Practice Location Address Fax Number: 
785-827-1327
    Provider Enumeration Date: 
10/25/2006