Provider First Line Business Practice Location Address:
920 6TH AVE
Provider Second Line Business Practice Location Address:
MEDICAL ARTS BLDG, SUITE 101
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-3225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-682-2595
Provider Business Practice Location Address Fax Number:
913-682-2595
Provider Enumeration Date:
11/01/2011