Provider First Line Business Practice Location Address:
315 W 15TH ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
LIBERAL
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-624-0729
Provider Business Practice Location Address Fax Number:
620-624-2569
Provider Enumeration Date:
12/14/2009