Provider First Line Business Practice Location Address:
505 E 16TH ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
WELLINGTON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67152-2811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-326-7455
Provider Business Practice Location Address Fax Number:
620-326-2880
Provider Enumeration Date:
04/09/2010