Provider First Line Business Practice Location Address:
225 W HIGHWAY 32
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LICKING
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65542-9832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-674-2207
Provider Business Practice Location Address Fax Number:
573-674-2239
Provider Enumeration Date:
06/30/2005