Provider First Line Business Practice Location Address:
119 E BOOTH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRETTY PRAIRIE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-602-6226
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2007