Provider First Line Business Practice Location Address: 
207 EDUCATION WAY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FORT LEAVENWORTH
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66027-1425
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
913-651-7373
    Provider Business Practice Location Address Fax Number: 
913-758-6010
    Provider Enumeration Date: 
09/09/2009