Provider First Line Business Practice Location Address: 
1947 N FOUNDERS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WICHITA
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67206-3548
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
316-689-9175
    Provider Business Practice Location Address Fax Number: 
316-613-4735
    Provider Enumeration Date: 
08/07/2006