Provider First Line Business Practice Location Address:
RR 3 BOX 164AD
Provider Second Line Business Practice Location Address:
1366 E 24 HIGHWAY
Provider Business Practice Location Address City Name:
MOBERLY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65270-9531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-263-2267
Provider Business Practice Location Address Fax Number:
660-263-7058
Provider Enumeration Date:
10/27/2005