Provider First Line Business Practice Location Address:
236 SAN JOSE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-2732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-225-8230
Provider Business Practice Location Address Fax Number:
620-225-8239
Provider Enumeration Date:
10/19/2006