Provider First Line Business Practice Location Address:
604 E 99TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64131-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
820-649-5641
Provider Business Practice Location Address Fax Number:
351-481-3352
Provider Enumeration Date:
04/16/2026