Provider First Line Business Practice Location Address:
101 N BROADWAY ST
Provider Second Line Business Practice Location Address:
STE #A
Provider Business Practice Location Address City Name:
PITTSBURG
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66762-4804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-232-3277
Provider Business Practice Location Address Fax Number:
620-231-6680
Provider Enumeration Date:
10/17/2005