Provider First Line Business Practice Location Address: 
1445 N RIDGE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WICHITA
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67212-2985
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
316-722-2166
    Provider Business Practice Location Address Fax Number: 
316-722-0949
    Provider Enumeration Date: 
07/06/2007