Provider First Line Business Practice Location Address: 
4810 STATE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KANSAS CITY
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66102-1748
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
816-221-0305
    Provider Business Practice Location Address Fax Number: 
816-221-9121
    Provider Enumeration Date: 
07/02/2020