Provider First Line Business Practice Location Address:
2125 N PENN AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67301-2142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-305-8099
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2016