Provider First Line Business Practice Location Address:
101 S FRONTAGE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67855-0572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-492-6879
Provider Business Practice Location Address Fax Number:
620-492-1445
Provider Enumeration Date:
04/27/2006