Provider First Line Business Practice Location Address:
616 E 63RD ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64110-3364
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-209-5005
Provider Business Practice Location Address Fax Number:
816-787-1347
Provider Enumeration Date:
04/07/2016