Provider First Line Business Practice Location Address:
104 W MARKET ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
OSAGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66523-1277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-528-1123
Provider Business Practice Location Address Fax Number:
785-528-4123
Provider Enumeration Date:
08/16/2010