Provider First Line Business Practice Location Address:
1302 SOUTH MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-242-3891
Provider Business Practice Location Address Fax Number:
785-242-3891
Provider Enumeration Date:
09/29/2006