Provider First Line Business Practice Location Address:
108 E 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICINE LODGE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67104-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-213-1016
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2010