Provider First Line Business Practice Location Address:
3601 S 4TH ST
Provider Second Line Business Practice Location Address:
SUITE #5
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-5015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-220-5193
Provider Business Practice Location Address Fax Number:
913-814-9989
Provider Enumeration Date:
06/01/2006