Provider First Line Business Practice Location Address:
215 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST PRAIRIE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63845-1123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-649-9082
Provider Business Practice Location Address Fax Number:
573-649-9626
Provider Enumeration Date:
08/02/2012