Provider First Line Business Practice Location Address:
1100 N 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-1572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-297-9945
Provider Business Practice Location Address Fax Number:
913-297-9628
Provider Enumeration Date:
06/29/2006