Provider First Line Business Practice Location Address:
145 NW 100TH TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64155-3404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-427-0716
Provider Business Practice Location Address Fax Number:
718-505-1807
Provider Enumeration Date:
02/11/2026