Provider First Line Business Practice Location Address: 
605 W LINCOLN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LINDSBORG
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67456
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-227-3371
    Provider Business Practice Location Address Fax Number: 
785-227-3004
    Provider Enumeration Date: 
04/21/2006