Provider First Line Business Practice Location Address:
3550 S. 4TH ST.
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-5061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-772-6046
Provider Business Practice Location Address Fax Number:
913-758-0500
Provider Enumeration Date:
04/24/2006