Provider First Line Business Practice Location Address:
107 NORTH PINE SUITE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PITTSBURG
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-232-5680
Provider Business Practice Location Address Fax Number:
620-232-5765
Provider Enumeration Date:
10/23/2006