Provider First Line Business Practice Location Address:
3515 S 4TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-651-8415
Provider Business Practice Location Address Fax Number:
913-772-8580
Provider Enumeration Date:
12/06/2006