Provider First Line Business Practice Location Address:
1808 EAST HIGHWAY 50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67878-0359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-794-4631
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2007