Provider First Line Business Practice Location Address:
107 W LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLINGTON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67152-3858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-326-8935
Provider Business Practice Location Address Fax Number:
620-326-6496
Provider Enumeration Date:
03/02/2007