Provider First Line Business Practice Location Address:
404 N. CHESTNUT ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67855-0779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-492-6250
Provider Business Practice Location Address Fax Number:
620-492-1447
Provider Enumeration Date:
09/08/2006