Provider First Line Business Practice Location Address:
1302 S MAIN ST STE 11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66067-3533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-242-8965
Provider Business Practice Location Address Fax Number:
785-242-6947
Provider Enumeration Date:
11/08/2007