Provider First Line Business Practice Location Address:
223 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65712-1410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-466-3443
Provider Business Practice Location Address Fax Number:
417-466-3443
Provider Enumeration Date:
11/02/2005