Provider First Line Business Practice Location Address: 
8623 E 32ND ST. N
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
WICHITA
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67226
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
316-869-2888
    Provider Business Practice Location Address Fax Number: 
316-634-8891
    Provider Enumeration Date: 
04/12/2017