Provider First Line Business Practice Location Address: 
238 S JEFFERSON AVE
    Provider Second Line Business Practice Location Address: 
SUITE A.
    Provider Business Practice Location Address City Name: 
LEBANON
    Provider Business Practice Location Address State Name: 
MO
    Provider Business Practice Location Address Postal Code: 
65536-3240
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
417-532-9922
    Provider Business Practice Location Address Fax Number: 
417-532-0199
    Provider Enumeration Date: 
03/09/2006