Provider First Line Business Practice Location Address:
8675 SE 72ND TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAXTER SPRINGS
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66713-3186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-848-3797
Provider Business Practice Location Address Fax Number:
620-878-3017
Provider Enumeration Date:
07/07/2005