Provider First Line Business Practice Location Address:
103 SCOTT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SCOTT
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66701-1420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-223-5210
Provider Business Practice Location Address Fax Number:
620-223-5213
Provider Enumeration Date:
05/10/2007