Provider First Line Business Practice Location Address:
219 W MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66725-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-429-3484
Provider Business Practice Location Address Fax Number:
620-429-3484
Provider Enumeration Date:
08/30/2006