Provider First Line Business Practice Location Address:
11124 E 28TH ST N STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67226-4562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-247-1065
Provider Business Practice Location Address Fax Number:
316-462-5752
Provider Enumeration Date:
02/10/2026