Provider First Line Business Practice Location Address:
1630 OHIO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67010-2142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-262-2001
Provider Business Practice Location Address Fax Number:
316-775-3469
Provider Enumeration Date:
04/08/2011