Provider First Line Business Practice Location Address: 
1122 BROADWAY STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CONCORDIA
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66901-4516
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-243-4177
    Provider Business Practice Location Address Fax Number: 
785-243-4516
    Provider Enumeration Date: 
09/12/2006