Provider First Line Business Practice Location Address: 
200 W WEAVER AVE
    Provider Second Line Business Practice Location Address: 
P O BOX C
    Provider Business Practice Location Address City Name: 
JOHNSON
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67855-5000
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
620-492-6226
    Provider Business Practice Location Address Fax Number: 
620-492-1326
    Provider Enumeration Date: 
09/04/2009