Provider First Line Business Practice Location Address:
115 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL GROVE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66846-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-767-6800
Provider Business Practice Location Address Fax Number:
620-767-6858
Provider Enumeration Date:
06/08/2006