Provider First Line Business Practice Location Address:
2010 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-6442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-227-8622
Provider Business Practice Location Address Fax Number:
620-227-7099
Provider Enumeration Date:
05/23/2008