Provider First Line Business Practice Location Address:
126 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICINE LODGE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-886-5161
Provider Business Practice Location Address Fax Number:
620-886-5517
Provider Enumeration Date:
10/07/2006