Provider First Line Business Practice Location Address:
301 NORTHEAST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63545-1005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-874-4127
Provider Business Practice Location Address Fax Number:
660-874-5010
Provider Enumeration Date:
02/27/2007