Provider First Line Business Practice Location Address:
1033 N KANSAS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERAL
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67901-2644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-624-4065
Provider Business Practice Location Address Fax Number:
620-626-8906
Provider Enumeration Date:
11/16/2005