Provider First Line Business Practice Location Address: 
708 CHAPEL STREET
    Provider Second Line Business Practice Location Address: 
BOX 67
    Provider Business Practice Location Address City Name: 
BALDWIN
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66006-0067
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-594-2721
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/04/2009