Provider First Line Business Practice Location Address:
3611 MAIN ST
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64111-2321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-561-7035
Provider Business Practice Location Address Fax Number:
816-960-3890
Provider Enumeration Date:
08/02/2005