Provider First Line Business Practice Location Address: 
201 E 99TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KANSAS CITY
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
64114-4152
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
816-474-3026
    Provider Business Practice Location Address Fax Number: 
816-474-3026
    Provider Enumeration Date: 
07/24/2007