Provider First Line Business Practice Location Address: 
3242 W 13TH ST N
    Provider Second Line Business Practice Location Address: 
SUITE 500
    Provider Business Practice Location Address City Name: 
WICHITA
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67203-6654
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
316-945-4488
    Provider Business Practice Location Address Fax Number: 
316-945-4499
    Provider Enumeration Date: 
11/24/2009