Provider First Line Business Practice Location Address:
2531 S 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-4512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-547-5755
Provider Business Practice Location Address Fax Number:
913-364-4823
Provider Enumeration Date:
03/27/2006