Provider First Line Business Practice Location Address:
902 HORTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SCOTT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66701-2438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-223-8090
Provider Business Practice Location Address Fax Number:
620-223-8092
Provider Enumeration Date:
03/29/2012