Provider First Line Business Practice Location Address:
12541 FOSTER ST STE 100
Provider Second Line Business Practice Location Address:
SOUTHRIDGE MEDICAL BLDG.
Provider Business Practice Location Address City Name:
OVERLAND PARK
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66213-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-932-2836
Provider Business Practice Location Address Fax Number:
816-932-9868
Provider Enumeration Date:
01/31/2008