Provider First Line Business Practice Location Address:
1100 N 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-1572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-807-0130
Provider Business Practice Location Address Fax Number:
480-807-0174
Provider Enumeration Date:
03/20/2007