Provider First Line Business Practice Location Address:
501 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
COUNCIL GROVE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66846-1355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-767-5282
Provider Business Practice Location Address Fax Number:
620-767-5292
Provider Enumeration Date:
10/28/2010