Provider First Line Business Practice Location Address:
1100 E MONTCLAIR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65807-5076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-820-8540
Provider Business Practice Location Address Fax Number:
417-820-8532
Provider Enumeration Date:
10/14/2005