Provider First Line Business Practice Location Address:
130 LOGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-4612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-489-0165
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2014