Provider First Line Business Practice Location Address:
606 BRIDGE STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-473-3212
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/16/2006