Provider First Line Business Practice Location Address:
947 1/2 ILLINOIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66044-2819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-849-5757
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2025