Provider First Line Business Practice Location Address:
1990 N 143RD ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67230-7164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-204-2470
Provider Business Practice Location Address Fax Number:
316-239-6747
Provider Enumeration Date:
03/15/2006