Provider First Line Business Practice Location Address:
100 HIGHWAY TERRACE
Provider Second Line Business Practice Location Address:
LVN DETENTION CENTER
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-680-6813
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2007