Provider First Line Business Practice Location Address:
921 W MYRTLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67301-3241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-331-2725
Provider Business Practice Location Address Fax Number:
620-331-2136
Provider Enumeration Date:
05/16/2007