Provider First Line Business Practice Location Address:
1624 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:
66701-2645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-223-5000
Provider Business Practice Location Address Fax Number:
620-223-5011
Provider Enumeration Date:
08/24/2012