Provider First Line Business Practice Location Address:
90 E LESLIE LN
Provider Second Line Business Practice Location Address:
C/O PHOENIX PROGRAMS, INC.
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65202-1535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-875-8880
Provider Business Practice Location Address Fax Number:
573-442-3830
Provider Enumeration Date:
02/22/2013