Provider First Line Business Practice Location Address:
2004 1ST AVE STE A
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:
67801-2697
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-225-1033
Provider Business Practice Location Address Fax Number:
620-227-8491
Provider Enumeration Date:
08/31/2006