Provider First Line Business Practice Location Address:
6500 W 143RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OVERLAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66223-2174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-214-2722
Provider Business Practice Location Address Fax Number:
833-973-5804
Provider Enumeration Date:
01/22/2026