Provider First Line Business Practice Location Address:
2307 SOUTH GORDON COOPER DRIVE
Provider Second Line Business Practice Location Address:
CITIZEN POTAWATOMI NATION/FIRELAKE WELLNESS CENTER
Provider Business Practice Location Address City Name:
SHAWNEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-395-9303
Provider Business Practice Location Address Fax Number:
405-395-9305
Provider Enumeration Date:
07/02/2006