Provider First Line Business Practice Location Address:
1031 S EDGEMOOR 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:
67218-3339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-973-7350
Provider Business Practice Location Address Fax Number:
316-973-7410
Provider Enumeration Date:
10/01/2026