Provider First Line Business Practice Location Address:
200 S EAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66725-1955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-429-2636
Provider Business Practice Location Address Fax Number:
620-429-2997
Provider Enumeration Date:
09/16/2006