Provider First Line Business Practice Location Address:
118 W. 4TH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBO
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-256-6346
Provider Business Practice Location Address Fax Number:
620-256-6219
Provider Enumeration Date:
03/24/2006