Provider First Line Business Practice Location Address:
714 BALLINGER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67846-5918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-275-0291
Provider Business Practice Location Address Fax Number:
620-275-0364
Provider Enumeration Date:
01/25/2013