Provider First Line Business Practice Location Address:
1301 W 12TH AVE STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMPORIA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66801-2588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-343-2376
Provider Business Practice Location Address Fax Number:
620-343-5989
Provider Enumeration Date:
06/29/2006