Provider First Line Business Practice Location Address:
505 N JOHNSON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67878-1008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-384-5598
Provider Business Practice Location Address Fax Number:
620-384-6812
Provider Enumeration Date:
06/26/2007