Provider First Line Business Practice Location Address:
1418 S MAIN ST
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66067-3544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-229-3530
Provider Business Practice Location Address Fax Number:
785-229-3529
Provider Enumeration Date:
05/23/2005