Provider First Line Business Practice Location Address:
414 WALLACE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64125-1132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-242-4206
Provider Business Practice Location Address Fax Number:
816-920-6627
Provider Enumeration Date:
03/02/2017