Provider First Line Business Practice Location Address:
1423 N NATIONAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65802-2047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-269-6583
Provider Business Practice Location Address Fax Number:
417-269-6573
Provider Enumeration Date:
11/08/2005