Provider First Line Business Practice Location Address:
2526 S MAIN 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:
66701-8724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-223-1666
Provider Business Practice Location Address Fax Number:
620-223-1856
Provider Enumeration Date:
07/01/2014