Provider First Line Business Practice Location Address:
210 SOULE ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-2558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-227-2503
Provider Business Practice Location Address Fax Number:
260-227-9905
Provider Enumeration Date:
04/04/2012