Provider First Line Business Practice Location Address:
1604 S NATIONAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SCOTT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66701-2645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-223-2140
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2018