Provider First Line Business Practice Location Address: 
620 W 32ND ST STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JOPLIN
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
64804-2528
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
417-621-0500
    Provider Business Practice Location Address Fax Number: 
417-781-5809
    Provider Enumeration Date: 
12/29/2005