Provider First Line Business Practice Location Address:
205 5TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-589-1661
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2007