Provider First Line Business Practice Location Address:
624 S NATIONAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SCOTT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66701-1317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-223-6440
Provider Business Practice Location Address Fax Number:
620-223-6998
Provider Enumeration Date:
09/27/2006