Provider First Line Business Practice Location Address:
2067 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAXTER SPRINGS
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66713-2657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-856-5418
Provider Business Practice Location Address Fax Number:
620-856-1932
Provider Enumeration Date:
05/10/2012