Provider First Line Business Practice Location Address:
500 E 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH COFFEYVILLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74072-0190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-255-6475
Provider Business Practice Location Address Fax Number:
198-255-6230
Provider Enumeration Date:
09/21/2005