Provider First Line Business Practice Location Address: 
712 ST. JOHN ST.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GARDEN CITY
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67846
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
620-275-1766
    Provider Business Practice Location Address Fax Number: 
620-275-4729
    Provider Enumeration Date: 
07/31/2014