Provider First Line Business Practice Location Address:
621 S 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67301-4311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-926-0305
Provider Business Practice Location Address Fax Number:
620-331-4766
Provider Enumeration Date:
01/23/2008