Provider First Line Business Practice Location Address:
124 COMMODORE ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PRATT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67124-2993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-672-6454
Provider Business Practice Location Address Fax Number:
620-672-3488
Provider Enumeration Date:
07/11/2006