Provider First Line Business Practice Location Address:
103 W SUNNYSIDE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTEZUMA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67867-0355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-846-2293
Provider Business Practice Location Address Fax Number:
620-846-2294
Provider Enumeration Date:
10/14/2009