Provider First Line Business Practice Location Address:
3550 S 4TH ST
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-5071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-788-9797
Provider Business Practice Location Address Fax Number:
913-788-5263
Provider Enumeration Date:
09/01/2005