Provider First Line Business Practice Location Address:
3515 S 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048-5013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-845-8550
Provider Business Practice Location Address Fax Number:
816-219-6965
Provider Enumeration Date:
05/26/2006