Provider First Line Business Practice Location Address:
1115 S GLENDALE ST STE 204
Provider Second Line Business Practice Location Address:
PARKLANE SHOPPING CENTER LOWER LEVEL
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67218-3232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-409-5242
Provider Business Practice Location Address Fax Number:
316-719-2440
Provider Enumeration Date:
02/21/2013