Provider First Line Business Practice Location Address:
1017 KENTUCKY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66044-2917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-749-1563
Provider Business Practice Location Address Fax Number:
785-843-3219
Provider Enumeration Date:
05/28/2006