Provider First Line Business Practice Location Address:
624 BRIDGE ST
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:
66748-1733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-473-2772
Provider Business Practice Location Address Fax Number:
620-473-3573
Provider Enumeration Date:
09/25/2006