Provider First Line Business Practice Location Address:
204 STATE STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-223-0130
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2007