Provider First Line Business Practice Location Address:
226 E. HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65101-1051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-636-4022
Provider Business Practice Location Address Fax Number:
573-635-7687
Provider Enumeration Date:
08/04/2006