Provider First Line Business Practice Location Address: 
4121 W 83RD ST
    Provider Second Line Business Practice Location Address: 
SUITE 227
    Provider Business Practice Location Address City Name: 
PRAIRIE VILLAGE
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66208-5300
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
913-648-1212
    Provider Business Practice Location Address Fax Number: 
913-381-2522
    Provider Enumeration Date: 
08/18/2006