Provider First Line Business Practice Location Address:
1122 BROADWAY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORDIA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66901-4316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-243-4177
Provider Business Practice Location Address Fax Number:
785-243-4516
Provider Enumeration Date:
09/12/2006