Provider First Line Business Practice Location Address:
1201 W 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGGINSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-584-4224
Provider Business Practice Location Address Fax Number:
660-584-7139
Provider Enumeration Date:
02/16/2007