Provider First Line Business Practice Location Address:
2229 S MAIN 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:
66701-3023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-223-2402
Provider Business Practice Location Address Fax Number:
620-223-4921
Provider Enumeration Date:
10/26/2012