Provider First Line Business Practice Location Address:
1003 W KINGMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKIN
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67860-9801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-355-6761
Provider Business Practice Location Address Fax Number:
620-355-7317
Provider Enumeration Date:
09/09/2009