Provider First Line Business Practice Location Address: 
2900 AMHERST AVE
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
MANHATTAN
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66503-3043
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-539-8700
    Provider Business Practice Location Address Fax Number: 
785-776-9788
    Provider Enumeration Date: 
04/21/2006