Provider First Line Business Practice Location Address:
2811 AVENUE A
Provider Second Line Business Practice Location Address:
APT. A
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-2164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-371-6140
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2006