Provider First Line Business Practice Location Address:
10250 COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRATT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67124-8195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-223-7847
Provider Business Practice Location Address Fax Number:
405-715-3325
Provider Enumeration Date:
10/29/2012