Provider First Line Business Practice Location Address:
1301 W 12TH AVE
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
EMPORIA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66801-2588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-343-1191
Provider Business Practice Location Address Fax Number:
620-343-3139
Provider Enumeration Date:
05/31/2005