Provider First Line Business Practice Location Address:
4105 W 6TH ST
Provider Second Line Business Practice Location Address:
SUITE B2
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66049-4609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-766-0641
Provider Business Practice Location Address Fax Number:
785-841-0026
Provider Enumeration Date:
09/20/2010