Provider First Line Business Practice Location Address: 
11118 COLLEGE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KANSAS CITY
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
64137-2220
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
816-564-2466
    Provider Business Practice Location Address Fax Number: 
816-965-7420
    Provider Enumeration Date: 
03/07/2008