Provider First Line Business Practice Location Address:
620A N MCKNIGHT RD
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
UNIVERSITY CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-432-5988
Provider Business Practice Location Address Fax Number:
314-432-2074
Provider Enumeration Date:
08/30/2006