Provider First Line Business Practice Location Address:
1126 S HORTON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SCOTT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66701-8200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-644-5019
Provider Business Practice Location Address Fax Number:
620-644-5002
Provider Enumeration Date:
03/05/2020