Provider First Line Business Practice Location Address: 
122 N MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HILLSBORO
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67063
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
620-947-3114
    Provider Business Practice Location Address Fax Number: 
620-947-5690
    Provider Enumeration Date: 
03/13/2015