Provider First Line Business Practice Location Address:
524 N BAEHR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67212-2220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-944-2087
Provider Business Practice Location Address Fax Number:
316-944-2087
Provider Enumeration Date:
01/18/2013