Provider First Line Business Practice Location Address:
412 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67301-3517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-331-3292
Provider Business Practice Location Address Fax Number:
620-331-1925
Provider Enumeration Date:
11/03/2006