Provider First Line Business Practice Location Address: 
505 S BROADWAY AVE
    Provider Second Line Business Practice Location Address: 
#114
    Provider Business Practice Location Address City Name: 
WICHITA
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67202-3900
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
316-200-5605
    Provider Business Practice Location Address Fax Number: 
316-272-9141
    Provider Enumeration Date: 
03/31/2016