Provider First Line Business Practice Location Address:
229 S KICKAPOO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH HAVEN
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67140-8819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-892-5215
Provider Business Practice Location Address Fax Number:
620-892-5814
Provider Enumeration Date:
09/11/2009