Provider First Line Business Practice Location Address: 
142 S PENN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OBERLIN
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67749-2243
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-475-2285
    Provider Business Practice Location Address Fax Number: 
785-470-2470
    Provider Enumeration Date: 
12/03/2014