Provider First Line Business Practice Location Address:
13 S NATIONAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SCOTT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66701-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-200-4872
Provider Business Practice Location Address Fax Number:
620-223-1445
Provider Enumeration Date:
06/18/2014