Provider First Line Business Practice Location Address:
3460 N. RIDGE RD.
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-684-2838
Provider Business Practice Location Address Fax Number:
316-684-2838
Provider Enumeration Date:
12/30/2005