Provider First Line Business Practice Location Address:
120 N 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67301-3759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-332-2528
Provider Business Practice Location Address Fax Number:
620-331-1628
Provider Enumeration Date:
06/15/2005