Provider First Line Business Practice Location Address:
5319 S SPRUCE ST
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:
67216-3246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-796-4147
Provider Business Practice Location Address Fax Number:
316-529-4510
Provider Enumeration Date:
03/13/2013