Provider First Line Business Practice Location Address:
1042 W 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66067-3951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-242-1127
Provider Business Practice Location Address Fax Number:
785-242-1536
Provider Enumeration Date:
09/06/2005