Provider First Line Business Practice Location Address:
1700 AVENUE G
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-4544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-255-8006
Provider Business Practice Location Address Fax Number:
620-371-7304
Provider Enumeration Date:
11/21/2016