Provider First Line Business Practice Location Address:
126 MISSOURI AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT. LEONARD WOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-596-0456
Provider Business Practice Location Address Fax Number:
573-596-0527
Provider Enumeration Date:
05/28/2010