Provider First Line Business Practice Location Address:
2055 S 143RD ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67230-9547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-973-9990
Provider Business Practice Location Address Fax Number:
316-973-9995
Provider Enumeration Date:
10/01/2026