Provider First Line Business Practice Location Address: 
1 UNIVERSITY PLZ MS 3333
    Provider Second Line Business Practice Location Address: 
SOUTHEAST MISSOURI STATE UNIVERSITY
    Provider Business Practice Location Address City Name: 
CAPE GIRARDEAU
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
63701
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
573-651-5152
    Provider Business Practice Location Address Fax Number: 
573-651-2532
    Provider Enumeration Date: 
03/07/2011