Provider First Line Business Practice Location Address:
106 E. GREENWOOD NORTH
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:
67855-0502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-492-1595
Provider Business Practice Location Address Fax Number:
620-492-2384
Provider Enumeration Date:
08/22/2005