Provider First Line Business Practice Location Address:
605A W 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAMAR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64759-1703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-682-5838
Provider Business Practice Location Address Fax Number:
417-682-5811
Provider Enumeration Date:
03/28/2007