Provider First Line Business Practice Location Address:
1020 PINE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-473-2393
Provider Business Practice Location Address Fax Number:
620-473-2359
Provider Enumeration Date:
07/10/2006