Provider First Line Business Practice Location Address:
107A N. MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICINE LODGE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67104-1316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-886-3120
Provider Business Practice Location Address Fax Number:
620-886-3129
Provider Enumeration Date:
06/04/2006