Provider First Line Business Practice Location Address:
701 N WALNUT ST
Provider Second Line Business Practice Location Address:
DRAWER 'C'
Provider Business Practice Location Address City Name:
MEDICINE LODGE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67104-1018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-886-3771
Provider Business Practice Location Address Fax Number:
620-886-5012
Provider Enumeration Date:
01/26/2007