Provider First Line Business Practice Location Address:
1137 NW SOUTH SHORE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64151-1439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-699-0947
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/07/2026