Provider First Line Business Practice Location Address:
204 E LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLINGTON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67152-3061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-326-6261
Provider Business Practice Location Address Fax Number:
620-326-6172
Provider Enumeration Date:
01/19/2006