Provider First Line Business Practice Location Address:
319 RIDGE ST
Provider Second Line Business Practice Location Address:
BOX #992
Provider Business Practice Location Address City Name:
TONGANOXIE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66086-9304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-845-0061
Provider Business Practice Location Address Fax Number:
913-369-3155
Provider Enumeration Date:
07/24/2006