Provider First Line Business Practice Location Address:
803 W CLARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67010-1346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-775-5001
Provider Business Practice Location Address Fax Number:
316-775-1614
Provider Enumeration Date:
05/01/2006