Provider First Line Business Practice Location Address:
710 N WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICINE LODGE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67104-1019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-526-0340
Provider Business Practice Location Address Fax Number:
972-996-1857
Provider Enumeration Date:
03/24/2006