Provider First Line Business Practice Location Address:
4116 BALTIMORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KANSAS CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64111-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-346-4768
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2026