Provider First Line Business Practice Location Address:
961 240TH ST
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:
66701-1674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-406-8040
Provider Business Practice Location Address Fax Number:
515-864-0150
Provider Enumeration Date:
06/12/2007