Provider First Line Business Practice Location Address:
188 W 720TH 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:
66701-8782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-362-3351
Provider Business Practice Location Address Fax Number:
620-362-3352
Provider Enumeration Date:
03/20/2008