Provider First Line Business Practice Location Address:
1503 OHIO ST
Provider Second Line Business Practice Location Address:
LEAVENWORTH
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-2932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-758-1149
Provider Business Practice Location Address Fax Number:
913-758-1149
Provider Enumeration Date:
07/31/2006