Provider First Line Business Practice Location Address:
120 E 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67010-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-351-7138
Provider Business Practice Location Address Fax Number:
316-295-4786
Provider Enumeration Date:
08/31/2015