Provider First Line Business Practice Location Address:
112 W ROSS BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
DODGE CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67801-7219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-227-2064
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2009