Provider First Line Business Practice Location Address:
109 E. 11TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERAL
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67901-2762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-624-8500
Provider Business Practice Location Address Fax Number:
620-624-8510
Provider Enumeration Date:
11/29/2005