Provider First Line Business Practice Location Address:
200 SAINT MARYS MEDICAL PLZ
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65101-1604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-761-7243
Provider Business Practice Location Address Fax Number:
573-761-7196
Provider Enumeration Date:
06/30/2006