Provider First Line Business Practice Location Address:
8821 N CONGRESS AVE APT 1122
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:
64153-1893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-341-8167
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2025