Provider First Line Business Practice Location Address:
2501 E 12TH ST APT 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64127-1386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-582-5645
Provider Business Practice Location Address Fax Number:
816-582-5645
Provider Enumeration Date:
02/16/2026