Provider First Line Business Practice Location Address:
536 FIRESIDE COURT
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66049-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-841-0307
Provider Business Practice Location Address Fax Number:
785-832-1710
Provider Enumeration Date:
10/19/2006