Provider First Line Business Practice Location Address:
3491 SE 45TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66725-2468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-399-6703
Provider Business Practice Location Address Fax Number:
620-371-2244
Provider Enumeration Date:
09/29/2025