Provider First Line Business Practice Location Address: 
105 W FERN STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SUBLETTE
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67877-0670
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
620-675-2277
    Provider Business Practice Location Address Fax Number: 
620-675-2652
    Provider Enumeration Date: 
09/23/2009