Provider First Line Business Practice Location Address:
1212 W 3RD ST N STE T1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67203-5939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-688-2007
Provider Business Practice Location Address Fax Number:
316-661-1208
Provider Enumeration Date:
01/06/2026