Provider First Line Business Practice Location Address:
122 W MYRTLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67301-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-577-4062
Provider Business Practice Location Address Fax Number:
620-577-4064
Provider Enumeration Date:
08/18/2015