Provider First Line Business Practice Location Address:
847 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66067-2805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-242-4133
Provider Business Practice Location Address Fax Number:
785-242-4187
Provider Enumeration Date:
09/17/2006