Provider First Line Business Practice Location Address:
4930 NW 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67114-8609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-283-6782
Provider Business Practice Location Address Fax Number:
316-283-6782
Provider Enumeration Date:
07/17/2007