Provider First Line Business Practice Location Address:
1000 2ND
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-0460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-227-1621
Provider Business Practice Location Address Fax Number:
620-227-1774
Provider Enumeration Date:
10/15/2009