Provider First Line Business Practice Location Address:
503 ELM
Provider Second Line Business Practice Location Address:
BOX 26, SUITE 1
Provider Business Practice Location Address City Name:
WAMEGO
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66547-0026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-456-2330
Provider Business Practice Location Address Fax Number:
785-456-9740
Provider Enumeration Date:
09/27/2006