Provider First Line Business Practice Location Address:
514 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67010-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-775-0077
Provider Business Practice Location Address Fax Number:
316-775-2718
Provider Enumeration Date:
08/30/2006