Provider First Line Business Practice Location Address:
1002 S 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIOWA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67070-1825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-825-4131
Provider Business Practice Location Address Fax Number:
620-825-4753
Provider Enumeration Date:
08/30/2005