Provider First Line Business Practice Location Address: 
2619 W. 6TH ST
    Provider Second Line Business Practice Location Address: 
SUITE C
    Provider Business Practice Location Address City Name: 
LAWRENCE
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66049
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-830-8299
    Provider Business Practice Location Address Fax Number: 
614-263-8268
    Provider Enumeration Date: 
04/18/2011