Provider First Line Business Practice Location Address:
120 W JOSEPHINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67010-2037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-775-5432
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2006