Provider First Line Business Practice Location Address:
236 SAN JOSE ROOM 125 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-2720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-408-4728
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2020