Provider First Line Business Practice Location Address:
4430 MISSOURI AVE
Provider Second Line Business Practice Location Address:
BLDG 885 W 16TH ST
Provider Business Practice Location Address City Name:
FORT LEONARD WOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65473-9098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-596-1898
Provider Business Practice Location Address Fax Number:
573-596-0405
Provider Enumeration Date:
12/18/2006