Provider First Line Business Practice Location Address:
2004 1ST AVE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-2623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-225-1033
Provider Business Practice Location Address Fax Number:
620-227-8491
Provider Enumeration Date:
05/18/2006