Provider First Line Business Practice Location Address:
111 S 9TH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66748-1809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-365-3115
Provider Business Practice Location Address Fax Number:
620-365-7717
Provider Enumeration Date:
01/10/2011