Provider First Line Business Practice Location Address:
1630 HUMBOLDT ST
Provider Second Line Business Practice Location Address:
APARTMENT D
Provider Business Practice Location Address City Name:
MANHATTAN
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66502-4166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-747-3807
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2013