Provider First Line Business Practice Location Address:
5015 E. 29TH STREET NORTH
Provider Second Line Business Practice Location Address:
'ENTRANCE T'
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-978-3289
Provider Business Practice Location Address Fax Number:
316-978-7264
Provider Enumeration Date:
11/27/2012