Provider First Line Business Practice Location Address: 
500 STATE HOSPITAL DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OSAWATOMIE
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66064-1813
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
913-488-8354
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/04/2011