Provider First Line Business Practice Location Address: 
843 S POPLAR ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WICHITA
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
67211-2832
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
316-689-8139
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/26/2007