Provider First Line Business Practice Location Address:
705 1ST AVE
Provider Second Line Business Practice Location Address:
SUITE 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:
67801-4437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-225-2522
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2006