Provider First Line Business Practice Location Address:
300 S AZTEC ST
Provider Second Line Business Practice Location Address:
APT. 17A
Provider Business Practice Location Address City Name:
MONTEZUMA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67867-8811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-846-7448
Provider Business Practice Location Address Fax Number:
620-846-7458
Provider Enumeration Date:
02/15/2007