Provider First Line Business Practice Location Address:
1100 SOUTH GRAND BLVD
Provider Second Line Business Practice Location Address:
ST LOUIS UNIVERSITH SCHOOL OF MEDICINE, DRC RM 433
Provider Business Practice Location Address City Name:
ST LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-977-9229
Provider Business Practice Location Address Fax Number:
314-977-9206
Provider Enumeration Date:
04/22/2013