Provider First Line Business Practice Location Address:
1201 W 136TH ST
Provider Second Line Business Practice Location Address:
T1840
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64145-1647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-412-0109
Provider Business Practice Location Address Fax Number:
816-412-0109
Provider Enumeration Date:
06/18/2011